Medicolegal Issues with Reference to NDPS and MHCA in Management and Rehabilitation of Persons with Substance Use Disorders.

Abstract

INTRODUCTION Substance use disorders (SUDs) are widely prevalent in India. As per the report, “Magnitude of substance use in India (2019),” about 6% of Indians aged 10–75 are affected by alcohol use disorders. This translates to about 6.7 crore individuals. An additional 1.5 crore people are estimated to be affected by drug use disorders.[1] A substantial part of practice of psychiatry in India is comprised the management of SUDs. The area of SUDs raises certain peculiar medicolegal issues, relevant for psychiatrists. As such, societal attitudes about substance use, in general, and SUDs especially tend to display a certain degree of hypocrisy. SUDs are among the most stigmatizing health conditions.[2] Some of these hypocritical and stigmatizing societal attitudes have influenced the laws and policies governing substance use. There is a commonly held misconception that stringent laws and their strict enforcement are the effective tools to address this problem, which is incorrect since SUD is in fact, primarily a health and welfare issue.[3] This, in turn, raises the intricacies that need to be negotiated by the psychiatrists while delivering care to their patients affected by SUDs. WHAT FACTORS RAISE “MEDICOLEGAL” ISSUES IN THE CONTEXT OF SUBSTANCE USE? Certain psychoactive substances have been totally “banned” under the law. Thus, not only their production and trafficking but also their consumption has been outlawed. Consequently, the very behavior – use of a substance– which brings a patient of SUD to a mental health provider, also attracts penal sanctions by the state. It may be noted that this issue of penalizing substance use is relevant not only for the discussion on the so-called “illegal” drugs but also the “legal” substances, the consumption of which may be regulated by the law. For instance, while tobacco is a legal substance, smoking in a designated nonsmoking area may attract penalties. Similarly, some states in India which have alcohol prohibition in place criminalize and heavily penalize the consumption of alcohol Use of intoxicating substances, whether occasional or regular, may result in a mental state of intoxication which may be associated with disinhibited behavior. Under this mental state, the affected individual is vulnerable to indulge in acts which are inappropriate or even illegal. This enhances the likelihood of a confrontation with the law enforcement apparatus SUDs are characterized by intense craving and distressing withdrawal symptoms which force the affected individual into a pattern of repetitive, compulsive use of the substance. To add to the complexity, many psychoactive substances are expensive (and rendered more expensive because of being illegal). Thus, financial difficulties, coupled with the need to consume the substance, may render the affected individual vulnerable to engage in criminal behaviors to procure the substance The complex and bidirectional association between substance use and mental illnesses (the comorbid nature) is well known. Consequently, all the (medico) legal issues relevant for mental illnesses, in general, remain relevant for SUDs as well On account of various factors, people who use drugs are known to be a group vulnerable for violation of their human rights by state and nonstate actors.[4] ABOUT THIS CHAPTER This chapter describes some of the medicolegal issues which are important for the mental health professionals (primarily the psychiatrists) to remain aware of while providing treatment and care to people affected by SUDs. Medicolegal issues primarily concerned with the two major laws – the Narcotic Drugs and Psychotropic Substances Act (NDPS Act) 1985[5] and the Mental Health Care Act (MHCA) 2017[6] – are dealt with in this chapter This chapter is NOT aimed at providing complete clinical practice guidelines on the treatment of SUDs. Specific documents published by the IPS exist for this purpose. As such, this chapter complements the earlier CPGs for SUDs developed by the IPS.[78] Similarly, some of the general medicolegal and ethical issues related to mental health care have been dealt with in other chapters of this series and hence are not repeated here As stated earlier, substance use itself may be present in the context of some other behaviors which bring the attention of the criminal justice system. This chapter does NOT address those issues (such as criminal liability in the state of acute intoxication) but limits itself to issues related to treatment as they pertain to the NDPS Act 1985 and the MHCA 2017 The laws and policies are dynamic and keep changing, more so, those governing the psychoactive substances. For instance, authorities may suddenly declare alcohol prohibition in some parts of the country, criminalizing alcohol consumption by everyone, including people with alcohol use disorders. Similarly, regulatory authorities may alter the scheduling of pharmaceutical products, changing the level of regulation exercised over their availability. Thus, a mental health-care provider needs to remain updated with the latest developments in this area This chapter, rather than providing an exhaustive list of all the relevant “facts” of the laws under discussion, seeks to sensitize the readers about the issues important for psychiatric practice through a description of their implications. The chapter encourages the reader to seek more detailed and updated information. Hence, rather than reproducing the laws and rules, the chapter provides references for the original sources for the same. The reader is advised to seek accurate and updated information from the original source. THE NARCOTIC DRUGS AND PSYCHOTROPIC SUBSTANCES ACT 1985 (NDPS ACT 1985): ISSUES RELEVANT FOR TREATMENT OF SUBSTANCE USE DISORDERS The NDPS Act (1985) has been described as a stringent law with many draconical provisions.[9] It was enacted with an aim to curb the production, trafficking, and consumption of the notified narcotic drugs and psychotropic substances while simultaneously ensuring their access and availability for medical and scientific purposes (the latter, italicized description of the Act came about as an amendment in 2014). The NDPS Act is relevant for the practice of psychiatry because of the following reasons: All individuals using any of the controlled narcotic drug or psychotropic substance potentially attract penalties under various provisions of the Act (irrespective of whether their usage pattern meets the professional definitions of a “SUD” or not) Some provisions of the Act deal specifically with the treatment of SUDs (described later) The Act lists certain pharmaceutical products as narcotic drugs or psychotropic substances. These medications, used by all the medial professionals and more so by the psychiatrists, are governed by the NDPS Act (even if they are not being used for treatment for SUDs, e.g., some benzodiazepines) (Note: Usage of ALL pharmaceutical products is governed by the provisions of the Drugs and Cosmetic Act (1940) and rules thereunder. Description of those issues is out of scope of this chapter. This chapter limits itself to discussing the issues covered under the NDPS Act 1985). The Narcotic Drugs and Psychotropic Substances Act (1985) and treatment of substance use disorders In the following section, we discuss some of the provisions of the NDPS Act (1985) which are related to the treatment of SUDs and their implications for psychiatrists. Section 2 (a) An “addict” has been defined in the Act as “a person who is dependent on any narcotic drug or psychotropic substance.” It may be noted that in the modern professional lexicon, an individual affected by SUDs is not termed as an “addict.” Indeed, the term addict to describe such an individual is considered highly stigmatizing.[10] In addition, by using the term “dependent” in the definition, the Act appears to have limited the scope of the term “addicts” to only those suffering from drug dependence. Implications People affected by dependence on the listed substances under the NDPS Act, and seeking treatment for the same, are recognized as “addicts” under the law. However, technically speaking, the law does not provide this status to people using the controlled narcotic drug or psychotropic substances in a pathological, yet nondependent pattern (i.e., people with a diagnosis of “harmful” use). The full import of this technicality becomes clearer in the subsequent passages where Sections 64A and 39 have been discussed. Section 4 (2) (d) and 7 These sections, in simple terms, state that treatment and rehabilitation of “addicts” is one of the measures that the central government must take and allocate funds for. Implications It must be noted here that the law, in effect, recognizes (a) existence of the entity called addiction or dependence and (b) need of treatment and rehabilitation for the same. This can be seen as one of the silver linings of the NDPS Act whereby it recognizes a clinical condition and provides for the remedy for the same. However, the terms “treatment” and “rehabilitation” are not defined anywhere in the Act. This is again fitting, since the scope and boundaries of what constitute treatment may keep changing with the advancements in science. Section 64 A With this section, the Act provides “immunity from prosecution to addicts volunteering for treatment.” As per this section, “Any addict, who is charged with an offence punishable under section 27 or with offences involving small quantity of narcotic drugs or psychotropic substances, who voluntarily seeks to undergo medical treatment for de-addiction from a hospital or an institution maintained or recognised by the Government or a local authority and undergoes such treatment shall not be liable to prosecution under section 27 or under any other section for offences involving small quantity of narcotic drugs or psychotropic substances.” Implications In simpler terms, people with drug dependence, if caught with a small quantity of drugs meant for personal consumption, can choose to undergo treatment and be exempt from prosecution. The specific quantities for various drugs have been defined as “small,” “intermediate,” and “commercial” in the Act (Table 1 provides an illustrative list of small and commercial quantities of some of the narcotic/psychotropic drugs). While on the face of it, this provision appears to be facilitatory for treatment; however, in practice, it is seldom invoked and utilized. One of the reasons for underutilization of this provision is that it forces the accused into admission of guilt (of possessing the drugs for personal consumption). The state/prosecution, on the other hand, invariably opposes this position and maintains that the drugs (even if in a small quantity) were being carried for the purpose of trafficking. If the legislative intent of this provision is to discourage criminalization of people with SUDs and encourage help seeking, this “implied admission of guilt,” in effect, seriously compromises that intent.[11] Thus, this onus of proof of being an “addict” falls upon the accused, which she/he finds difficult to prove. In addition, the quantity of the substance seized is also often disputed by the prosecution.[12]Table 1: Small and commercial quantities of some drugs under the Narcotic Drugs and Psychotropic Substances Act (Section 2)*Section 39 This section describes the provision whereby, instead of sentencing, courts can divert drug-dependent people convicted for consumption or an offense involving a small quantity of drugs, to a recognized medical facility for treatment. Implications Along with Section 64 A, this provision is also rarely utilized in practice. However, there is always a possibility that in a given case, the court may mandate the treatment of a person caught with small quantity of drugs (deemed to be meant for personal consumption on account of being an “addict”) and refer the accused to a specific treatment facility. The court may also ask for a proof of “completion of treatment.” The treatment provider in such cases will be expected to provide treatment as per the standard practice guidelines and inform the court (if asked) about the same. Section 71, 76 (2) (f), and 78 (2)(b) These sections empower the government to set up and regulate centers for the identification, treatment, and care of drug-dependent people. Implications Before enactment of the MHCA (2017), it was the NDPS Act (1985), under which the governments (union as well as state) were empowered to enforce the standards of addiction treatment. Indeed, the need of regulating a large number of addiction treatment services (“De-addiction centres” or “rehabilitation centres”) is a recognized challenge in India.[13] Very few state governments (Punjab and Haryana are the examples) utilized this provision of the NDPS Act and established rules (including licensing procedures) for regulating addiction treatment centers. However, with the MHCA (2017), these regulations of drug dependence treatment facilities (as a type of mental health establishment) are expected to be under the purview of the MHCA 2017 (described later). Thus, to summarize, it can be seen that the NDPS Act (1985) does recognize addiction as a health condition which needs treatment and rehabilitation (even if only as an afterthought); but unfortunately, it steers clear of providing adequate safeguards for the same. The Narcotic Drugs and Psychotropic Substances Act (1985) and the controlled medications In general, the NDPS Act is prohibitionist and punitive in nature.[14] For most of the provisions, the text of the Act states “No person shall….produce, manufacture, possess….(etc.)…(NDPS)……. except for medical and scientific purpose”. Thus, the law, in general, seeks to prohibit all the activities related to NDPS but makes an exception for the “medical and scientific purpose.” The phrase, “medical and scientific purpose” is however not defined. Considering many other provisions described under the Act, (including the 2014 amendment which specifically added the purpose of the Act to include simultaneously ensuring their [NDPS] access and availability for medical and scientific purposes), the Act does recognize the role of NDPS as medications. Indeed, Section 71 specifically empowers the government to “supply NDPS” where it is a “medical necessity.” It may be noted that the term “pharmaceutical” is not used in Section 71. In other words, the government is empowered to provide even the nonpharmaceutical narcotic drugs or psychotropic substances for a “medical necessity.” Implications Some psychiatrists harbor the misconception that addition of a medication in the list of controlled narcotic drugs or psychotropic substances amounts to it being “banned.” This is incorrect. Being categorized as a narcotic or psychotropic simply increases the level of regulations exercised over production and marketing of that medication. This primarily makes a difference at the level of production, manufacture, transport, and import/export. It must also be noted here that whether a narcotic or psychotropic medication is approved for treatment of a medical condition or not, and the level of regulation exercised over it is governed under a separate legal framework (i.e., the Drugs and Cosmetic Act and the rules thereunder). In the section below, issues related to both the categories of medication – narcotic and psychotropic – are discussed in the context of the NDPS Act as well the implications for the psychiatric practice. To begin with, the NDPS Act (1985) had the categories of “Narcotic” drugs, “Psychotropic” substances, and the “controlled substances” (referring to the precursor chemicals). By and large, this categorization of substances as Narcotic or psychotropic under the Indian NDPS Act has been based upon their categorization under the international drug regulatory framework (the three United Nations Drug Conventions). Thus, substances categorized as narcotics or psychotropics under the three UN conventions are scheduled under the same categories in India as well. However, there are exceptions. As an illustration of such exceptions, tramadol is not categorized as a psychotropic substance under the international regulatory framework. Government of India, on the other hand, has recently (in 2018) notified tramadol as a psychotropic substance under the NDPS Act.[15] However, to reiterate, whether tramadol is approved to be used as a medication and for what clinical indications, is not a mandate of the NDPS Act. A separate framework established under the Drugs and Cosmetic Act 1940 and the rules thereunder determines the usage of tramadol as a medication. Narcotic medications Primarily, the opioid analgesics, are among those medications which are scheduled as narcotic drugs under the NDPS Act. An important distinction must be made for the category of “Essential Narcotic Drugs (ENDs).” Through an amendment in the NDPS Act in the year 2014, certain medications were categorized under the NDPS Act as “ENDs:” morphine, codeine, oxycodone, hydrocodone, fentanyl, and most important for the purpose of addiction treatment, methadone. The NDPS Act amendment 2014 and the NDPS rules 2015, in essence, are aimed at facilitating the usage of these medications for the purpose of treatment of pain conditions and addiction treatment. In nutshell, the relevant rules for ENDs (the full set of rules as well as the formats are available at https://dor.gov.in/sites/default/files/Narcotic -Drugs-and-Psychotropic-Substances-Rules - 1985_0.pdf) are as follows: On the issue of who is eligible to prescribe ENDs, definition i (b) defines the “registered medical practitioner” as “any person registered as a medical practitioner under…. any law for the registration of medical practitioner …. and has undergone training in pain relief and palliative care for prescription of ENDs or training in opioid substitution therapy for prescription of ENDs for treatment of opioid dependence” (At the time of writing this document, the said rules and definitions are being considered for modifications. There is a demand from various stakeholders that the requirement of a specific type of training be removed from the definition so that any qualified and registered doctor working with a Recognized Medical Institution (RMI) is eligible to prescribe ENDs.) Rule 52G: Specifies the prescription of ENDs by a registered medical practitioner: “the prescription shall be in writing and dated and signed by the practitioner with his full name, address and registration number and shall specify the name and address of the-person to whom the prescription is given and the total quantity of the END to. be supplied along with daily dose and period of consumption.” It also specifies that doctors cannot prescribe these drugs to themselves (prescription for oneself) Rule 52H (2): Requires the medical practitioner to maintain detailed records of all transactions of ENDs in the specified format. This applies to those medical practitioners who stock and dispense the ENDs to their patients Rule 52H (3): Says that “Every registered medical practitioner shall also maintain a separate record for each patient and such record shall be preserved for a minimum period of two years.” It must be noted that the rule does not make it clear whether these records must be maintained only by those doctors who are stocking and dispensing ENDS or also by those just prescribing ENDs. Thus, it would be prudent for the doctors to maintain records of all patients who receive a prescription of ENDs, even if the doctors are not stocking and dispensing ENDs Similarly, on the issue of who is eligible to stock and dispense ENDs, the rules 52N and 52O describe a “RMI.” While any kind of government health-care facility is deemed to be RMI, the clinics or facilities in the private sector need to apply to the state controller of drugs to be designated as RMI in the prescribed format. More importantly, the RMI needs to have on board, registered medical practitioners who need to be “designated” to prescribe and dispense ENDs. The rule 52Q describes a designated medical practitioner as one “who has undergone training in pain relief and palliative care for prescription of ENDs for pain relief and palliative care or training in opioid substitution therapy for prescription of ENDs for treatment of opioid dependence” Regarding stocking and dispensing ENDs, the RMIs are expected to observe the following (in the prescribed formats): Get themselves recognized by the Controller of Drugs Submit an estimate of the annual requirement of the quantity of ENDs Maintain detailed records of stock/dispensing Submit annual returns. Thus, to summarize, the NDPS Act empowers all psychiatrists to stock, prescribe, and dispense all the ENDs, provided they observe the prescribed procedures. Among all the ENDs, methadone is most relevant for psychiatrists. Psychotropic medications The term psychotropic is often used (erroneously) by psychiatrists in their routine communication and discourse to denote all the medications used for the treatment of psychiatric disorders.[16] It must be noted that only some of the medicines used for psychiatric treatment (those which possess a liability for development of addiction) are categorized as psychotropic substances in the international drug control framework as well as the NDPS Act 1985. Thus, most of the antidepressants, antipsychotics, or mood stabilizers are NOT psychotropic substances under the NDPS Act. Some examples of medications which are scheduled as psychotropic substances (which are prescribed by the psychiatrists) are benzodiazepines (such as diazepam and alprazolam) and opioid agonists (such as tramadol and buprenorphine). In general, regulations on psychotropic medications are less stringent than those on narcotic medications. One notable exception is tablet buprenorphine (including the fixed-dose combination of buprenorphine and naloxone), for which there had been specific conditions imposed (over and above those for other psychotropic medications). Buprenorphine, besides being an analgesic, is one of the most effective opioid agonists for the treatment of opioid use disorders, but its wider availability and usage has been affected by the regulatory barriers.[17] Importantly, these additional barriers to the use of buprenorphine were not put under the NDPS Act, but by the pharmaceutical regulatory agencies (Central Drug Standard Control Organization), who had ordained that tablet buprenorphine, in effect, can only be used by “de-addiction centres.” This resulted in (a) poor availability of this useful medication for the treatment of opioid dependence in India and (b) harassment, including arrest and jail terms for some of the psychiatrists.[18] The saga of buprenorphine illustrates how use of a medication (like buprenorphine), which is regulated under two different laws – the NDPS Act and the Drugs and Cosmetic Act – could present unique legal challenges for the doctors. Alleged violation (or even a minor infarction) of one of the laws (the Drugs and Cosmetic Act) can potentially attract prosecution and penalties under another law (the NDPS Act). However, in the year 2018, the subject expert committee of CDSCO recommended that buprenorphine tablets can be used by “psychiatric clinics and hospitals,” paving the way for stocking and dispensing of buprenorphine by all the psychiatrists (including those providing treatment through stand-alone, outpatient clinics). More detailed guidelines, including the procedural and operational aspects of buprenorphine treatment, are available in the form of a recent IPS publication.[19] Under the NDPS rules, there are no specific regulations regarding the type of prescriptions for psychotropic medications. It is prudent, however, to follow the standard guidelines and rules for prescription, as released by the medical/pharmaceutical regulatory authorities from time to time for ALL the prescriptions, including those involving psychotropic medications. Regarding duration/amount of psychotropic medications which can be prescribed, it may be noted that under the rule 66 (2) of the NDPS, if prescribed by a medical practitioner, a patient may possess up to 300 dosage units of a psychotropic medication for his/her personal use. THE MENTAL HEALTH CARE ACT 2017 (MENTAL HEALTH CARE ACT 2017): ISSUES RELEVANT FOR TREATMENT OF SUBSTANCE USE DISORDERS While MHCA 2017 is revolutionary in many other aspects, it does pose some specific issues of concern for the treatment of SUDs. The MHCA 2017 has sought to explicitly include SUD in the definition of mental illnesses: “….a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs, but does not include mental retardation…” (emphasis added). Thus, it appears that the text of the definition under the Act is rather ambiguous, so far as inclusion of SUD as a mental illness is concerned. Unfortunately, this issue remains unclarified elsewhere in the document. First of all, in the phrase, “mental conditions associated with the abuse of alcohol and drugs,” the use of the word “abuse” is inappropriate since none of the recent versions of diagnostic and classificatory systems (DSM or ICD) have a diagnostic entity called “abuse.”[13] In addition, the complexity is enhanced with the phrase regarding mental illnesses – ”gross impairment of judgement, behaviour or capacity to recognise reality or ability to meet the ordinary demands of life.” It may be a debatable issue whether all SUDs meet these criteria? For all practical purpose, however, it can be accepted that SUDs are also mental illnesses and hence covered by the provisions of the MHCA 2017.[20] Capacity of patients with substance use disorders under the mental health care act 2017 The MHCA 2017 determines that a person with mental illness is deemed to have capacity if such a person has the ability to: “(a) Understand the information that is relevant to take a decision on the treatment or admission or personal assistance; or (b) Appreciate any reasonably foreseeable consequence of a decision; or lack of a decision on the treatment or admission or personal assistance; or (c) communicate the decision under sub-clause (a) by means of speech, expression, gesture, or any other means.” Other chapters in this series deal with the issue of capacity assessment in general, at greater lengths. As far as SUDs are concerned, the debate and controversy regarding the extent to which patients with SUDs retain their abilities to decide about using or not using drugs or seeking or not seeking treatment are well known. Denial and minimization of problems are recognized features of SUDs. Thus, especially in the context of assessment of “capacity” for SUDs, it has been recommended to “…. suspend the unilateral global presumption of capacity and instead assess decision-making capacity on a case-by-case basis….”.[21] In other words, even in those patients who can be diagnosed as SUDs, but who do not express willingness to undergo treatment, lack of capacity should not be assumed. Patients with SUDs must be provided treatment only with their explicit consent. However, under the MHCA (Section 89), people with mental illness can be admitted and treated without their consent, but with a request from a “nominated representative.” For this, certain conditions have been specified: If the person has “……tried or threatening to harm himself or has behaved violently or is causing another person to fear bodily harm from the person with mental illness, or has shown/is showing inability to care for himself to a degree that places the individual at risk of harm to himself” (emphasis added). Thus, clearly, the persons affected only by SUDs (without any other psychiatric comorbidity, which can result in such behaviors) are not fit for treatment without their consent. Hence, explicit consent of the patient is essential for receiving treatment for SUDs. Regulation of treatment services under the Mental Health Care Act 2017 The MHCA 2017 lays down various rights of people with mental illness (including SUDs), including those rights pertaining to “protection from cruel, inhuman or degrading treatment in any mental health establishment.” In India, a wide variety of entities are involved in providing care and treatment to people with SUDs. These include various government health-care facilities, those in the private sector as well as those in the NGO/charitable sector. Before MHCA 2017, there was a serious lack of clarity over regulations on these facilities (or “de-addiction centres”/”rehabilitation centres”). As noted earlier in this chapter, while the NDPS Act empowered the government to set up standards for the same, very few state governments took any steps in this regard. Under the Section 65 of MHCA 2017, the state governments have been empowered to lay down rules and minimum standards for all Mental Health Establishments (MHEs) (including those catering to people with SUDs, i. e. the de-addiction centers). However, at the time of writing this, to the best of the authors’ knowledge, neither most of the SMHAs established under the MHCA nor the CMHA has published guidelines/standards specifically for MHEs involved in the treatment of SUDs (i.e., the de-addiction centers). If a particular SMHA has not developed such guidelines or standards, it is expected that standards/guidelines published by the CMHA (as and when they are available and notified) shall have to be followed (At the time of writing this, the notification from CMHA regarding the same is awaited.). One state that has taken the lead in this area is the National Capital Territory (NCT) of Delhi, which notified the “Minimum standards of care for Centres providing SUD treatment and rehabilitation” for the NCT of Delhi in 2018.[22] As an illustration, salient features of this document are provided below. The document recognizes the existence of different types of facilities involved in the treatment of SUDs. Some facilities may primarily be catering to patients with acute or short-term treatment needs (such as providing “detoxification”), while others may be involved in providing long-term care (including psychosocial interventions aimed at rehabilitation). There may be some facilities providing care to those affected by comorbid SUD and other mental illnesses. Taking this into account, the document published for Delhi provides minimum standards for three broad categories of the facilities: Short-term treatment including detoxification center (<one-month treatment duration) Long-term treatment/rehabilitation center (>1-month treatment duration) Treatment center for SUDs and comorbid psychiatric disorders (i.e., dual diagnosis facilities). It is also understandable that the infrastructure and other requirements for such facilities would also be dependent upon their size (i.e., the number of patients they cater to). Hence, all the three categories have been further subdivided based on the number of beds (up to 20/20–50/>50). Accordingly, minimum standards have been prescribed for the same. The prescribed minimum standards span a range of areas in which the specified requirements need to be fulfilled. These areas include: Physical Infrastructure: In terms of area in square feet per bed, specific space requirement for children and adolescents, personal belongings of patients, etc. Human resources: Including numbers and qualification of staff such as doctors, nurses, counselors, etc., and their level of engagement Services: Including description of registration, inpatient treatment, pharmacotherapy, record maintenance, etc. The prescribed minimum standards are to be governed and monitored by the State Mental Health Authority. On the issue of “informed written consent,” the document specifically mentions that the provisions of MHCA 2017 will be applicable. It is understood that other state governments/CMHA would have formulated/would be formulating similar rules or standards governing treatment facilities for SUDs. All mental health professionals working with such facilities need to pursue and ensure compliance with these rules/standards. If the facilities registered under the MHCA 2017 are providing treatment using any of the pharmaceutical products which are regulated under the NDPS Act 1985, they are expected to comply with the provisions of the NDPS Act as well. TIPS FOR PSYCHIATRIST PROVIDING TREATMENT AND REHABILITATION SERVICES FOR SUBSTANCE USE DISORDERS All the general guidelines/rules/procedures for providing treatment services for other mental illnesses apply to services for SUDs as well “Consent of the patient” is the golden rule to be followed. For outpatient-only treatment, the “implied consent” may be adequate. However, for inpatient treatment, the consent needs to be written informed consent (as per the provisions of the MHCA 2017) For patients with SUDs with poor motivation for treatment, all attempts may be made to provide psychosocial interventions/counseling/motivation enhancement to encourage them to enter treatment. However, without the consent of the patient, avoid any intervention or treatment (specifically pharmacotherapy) If medicines which are notified as narcotic drugs are being prescribed, the specification mentioned in the section “Narcotic medications” needs to be followed Any facility involved in providing inpatient services for SUDs (such as a de-addiction center or a rehabilitation center) is essentially a mental health establishment under the MHCA 2017. Thus, the standard procedure for establishing such a facility, as prescribed under the MHCA 2017, needs to be followed. Receiving a grant from a government organization (such as in case of NGO-operated treatment centers which may receive a grant from the central or state governments) does not absolve the management of such a facility from the responsibility of complying with the MHCA 2017 If a psychiatrist is associated with a mental health establishment, either as an owner or a full-time or part-time staff, it needs to be ensured that the management of the establishment is aware of and complies with the provisions of MHCA 2017. If narcotic medications are being prescribed, stocked, and dispensed, ensure that the provisions of the NDPS Act 1985 are being complied with If psychiatrists are providing telepsychiatry services for patients with SUDs, they need to remain aware of the rules, guidelines, and issues involved in the same.[23] CONCLUSION SUDs are among the significant public health problems. Despite the high prevalence of SUDs, it is unfortunate that the two major laws of India – the NDPS Act 1985 and the MHCA 2017 – do not deal with the issues surrounding the treatment of SUDs adequately. However, the laws, as they stand today, provide enough opportunity for the psychiatrists to provide ethical and effective treatment to their patients, which are compliant with the law as well as follow the basic tenets of evidence-based medicine. All psychiatrists need to remain aware of nuances of the existing laws and deliver their services accordingly. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.