Kashmir’s healthcare system is struggling to cope with a mounting heroin epidemic

Patients wait at a de-addiction centre in Srinagar. SHAHID TANTRAY FOR THE CARAVAN
25 February, 2024

INSIDE A DIMLY LIT ROOM at the police-run de-addiction centre in north Kashmir’s Baramulla district, four boys were huddled together on a steel bed close to an electric heater. A tall, burly man stood guard at the door. Outside, the weather was frigid, as one would expect on a December afternoon in the Kashmir Valley. Omar, the youngest among the group, had been admitted to the centre two days earlier, by his concerned mother and uncle, who hoped that the centre might help him overcome his heroin dependency.

Omar hails from the frontier district of Kupwara, some fifty kilometres from Baramulla. He shoulders the responsibility of being the sole earner in his family of five. He told me that he works as a machine operator at his uncle’s bandsaw factory, scraping by on Rs 13,000 a month. His father has been confined to bed for many years, incapacitated by an accident long before Omar was born. His mother, hailing from West Bengal, devotes herself to caring for his father and his younger siblings. When asked about the perilous nature of his job, Omar proudly said that he had worked for many years without incident.

Omar told me that his descent into heroin addiction began nearly a year ago when he saw a younger cousin injecting something into his arm in an alley behind his house. “When I asked him what it was, he told me it’s a medicine to cure all the tension.” Naïve and inquisitive, he agreed to try the miracle cure. The two cousins began meeting in the alley every evening. “It gave me a really good feeling that is difficult to explain,” Omar said. “If you are on heroin, whatever is happening around won’t affect you. You feel strong. Then I started doing it during the day at lunchtime.” His arms were covered with deep blue scars—souvenirs of the countless injections he had administered.

Omar was not alone in his malady. Kashmir’s decades of conflict have etched a deep scar in its people’s mental health, a strain that often goes unacknowledged. One of its clearest symptoms has been an epidemic of drug use as a mode of escape, with cannabis in the past and heroin today. The heroin epidemic carries within it a second epidemic: of hepatitis C and other bloodborne viruses. The social stigma around drug use leads to it being underreported, and even those cases that reach a doctor find a health system that is severely underequipped and understaffed. With counselling being short and inaccessible, and some other regimens being ineffective, the doctors of Kashmir face an uphill battle. And the many I spoke to feared the fate of an entire generation rested in the balance.


KASHMIR IS LOCATED near the notorious Golden Crescent—a region, covering parts of Afghanistan, Pakistan and Iran, that has traditionally served as a route for trafficking heroin manufactured in Afghanistan. In 2021 alone, authorities in the region reportedly seized over a hundred and sixty kilograms of heroin. A 2022 study by the Institute of Mental Health and Neuro Sciences, in Srinagar, observed an “exponential rise” in substance abuse in the Kashmir Valley. On 4 August 2023, a parliamentary standing committee estimated that the union territory has around 1.35 million drug users.

Yasir Rather, an assistant professor of psychiatry at the IMHANS, told me that heroin use in Kashmir has spread like a “viral infection.” In 2016, he said, a few hundred users sought help at the institute’s de-addiction facility. In 2020, more than thirteen thousand patients sought treatment for heroin. Addiction Treatment Facilities—set up by the state government in collaboration with Delhi’s All India Institute of Medical Science—point to a similar trend. Since its inception in late 2021, the ATF at the Kulgam district hospital has received 813 patients dealing with heroin or opioid addiction. At the ATF in neighbouring Anantnag district, 1,154 patients sought treatment for heroin addiction in 2022 alone.

“Heroin has become the drug of choice,” Rather told me. “Almost ninety percent of cases we tend to are using it.” He added that “the majority of them are using intravenous methods to inject the drugs, which has led to multiple secondary health complications.” A 2019 study conducted by the AIIMS-run National Drug Dependency Treatment Centre found that over twenty-five thousand people in Jammu and Kashmir were injecting drugs intravenously, and that over seventy percent of users share needles. The quantum of work—an amalgamation of harmful usage and dependence that necessitates professional intervention—amounted to 1.5 percent, nearly double the national average. The weak health apparatus in the valley is often unable to cope.

Kashmiri youth hold up a banner and burn candles to observe the International Day against Drug Abuse and Illicit Trafficking in Srinagar, on 26 June 2021. YAWAR NAZIR / GETTY IMAGES

When Omar first visited the de-addiction centre, he told doctors he was 18 years old. They suspected he is much younger. He is also grossly underweight, a mere 36 kilograms. The doctors believed he had contracted hepatitis C, a viral infection that primarily affects the liver but can also have systemic effects throughout the body. They had sent his blood to a local government hospital, but the results were yet to arrive. Altaf Shah, who heads the centre, told me that over ninety percent of the patients seeking treatment for heroin dependency would test positive for hepatitis C. “It’s a virus that eats you from inside without showing any symptoms.”

The de-addiction centre was established in 2012. A year later, an in-patient department was started. The unassuming single-story structure has witnessed a steep rise in the number of heroin users admitted, from four in 2013 to 144 in 2021. Shah said they lack the infrastructure to deal with the number of heroin users reaching out for help in recent years, with only eight in-patient beds.

During the initial days of the centre, doctors primarily encountered two types of addiction cases: cannabis addiction and people who were misusing opioid-based painkillers. In recent years, though, the choice of drugs in Kashmir has become heroin. “Heroin has become alarmingly common, and I’m not talking about just the Baramulla district,” Shah worried. “We have cases coming from communities in far-flung areas, who had no concept of using such hard drugs. It’s as easily available as cigarettes. We have had cases where four or five members of the same family are addicted to heroin.”

Omar would have to stay at the facility for the next twenty days. During this period, Shah and his team hoped to ease out his dependence through abstinence and regular counselling. “Proper counselling is more important than medicine for the rehabilitation of heroin users,” Shah told me. “Giving them pills to overcome addiction makes them addicted to medicine. When he goes back home, it’s up to him to stay on the right path.” Shah acknowledged that Omar, after leaving the facility, would have to face the same peer pressure and psychological strain that pushed him to use heroin in the first place. The doctor also reluctantly acknowledged a disheartening reality: half the patients the centre treats ultimately relapse.


RIYAZ AHMAD HAD already spent a week at the de-addiction facility in Srinagar’s Shri Maharaja Hari Singh Hospital when I met him, in December 2022. His wife, Suraiya, was at his bedside. Ahmad, who is in his late thirties, told me that he had been using heroin for the past five years. He had tried to quit multiple times but failed. “This time it’s different, though,” he said. “I have to do it.” Ahmad took the decision to enter a 20-day rehabilitation programme at the hospital after his teenage daughter and son stopped talking to him. “I can’t let my shortcomings overcome the lives of my children,” he told me. “I can’t live with the thought of people calling them children of a heroin addict.”

Sometime in late 2017, Ahmad, who ran a successful construction business in Pulwama district, saw some of his workers smoking heroin during lunch break. He knew what heroin was but had never seen anyone consuming it. The group persuaded him to try it, saying that it gave them “energy.” He began smoking with them every day.

One day, the men moved to a different construction site, and Ahmad could not get his daily high. “I felt immense pain in my entire body,” he said. “I was vomiting and shivering. I went to a doctor, and he prescribed me some medicine, but it didn’t help.” He called the construction workers and they told him he was having tod—Kashmiri slang for withdrawal symptoms. They advised him to smoke heroin to ease the pain. “After that day, I never stopped smoking heroin,” Ahmad said. “For the next three years, I would smoke three or four grams a day. It came to a point where I had so many blisters in my mouth that I could not have food that had any spices in it. At lunch, I would just buy a packet of milk and go with plain rice. That’s all I could eat.”

Students rest on the bank of the river Jhelum in Srinagar, on 23 August 2012. Kashmir’s heroin epidemic is increasingly affecting a younger generation. YAWAR NAZIR / GETTY IMAGES

Instead of doctors, Ahmad turned to his heroin dealer for advice. The dealer suggested he use tichu—intravenous use—instead of smoking. Three months into injecting heroin, Ahmad developed severe swellings, which did not go unnoticed. His son was the first to question him, and then when his wife and mother confronted him. He confessed. “I told them I have committed a big mistake and, if they can forgive me, I’ll do whatever it takes to quit my addiction,” Ahmad said. “They got me admitted to a private de-addiction facility in Srinagar.” Owing to the heroin epidemic in Kashmir, a number of private de-addiction facilities have opened up, but nearly all of them are located in the capital. “It was a nice place,” Ahmad remembered. “But I felt the medication they gave me didn’t work.” By the time Ahmad reached the de-addiction facility at SMHS, he had already tested positive for hepatitis C, with a high viral load.

While there is no centralised data on hepatitis rates among heroin users, my interviews with doctors at ATFs in five districts pointed to a high prevalence. Fazal Ul Haq, the managing director of medicine at the SMHS facility, said that seven out of ten users they treat tested positive for hepatitis C. Treatment for hepatitis is available in all government-run hospitals, he said, but it takes a physical and emotional toll on recovering addicts. “Usually, patients with HCV are prescribed medicines for three months,” Haq said. “Most of them stop taking medication midway through, because they have either relapsed or just don’t feel like taking medications. A team of doctors from SMHS are currently working on a valley-wide study to find the prevalence and genotypes of HCV infections in users.”

Although no cases of HIV infections have yet been recorded among heroin users in the valley, experts worry that could change drastically if proper measures are not taken. “Because there have been outbreaks of HCV in Kashmir, that could be a reason for high prevalence among users, and because the number of HIV-positive patients are low in the state, it has spread yet,” Haq said. “But the risk is still high, given sharing of needles is very common and there is very little awareness.”

Haq also worried that other health implications of heroin use were not being studied. He pointed to a growing number of sudden deaths of young people being reported in the local media. “It is quite possible some of them died of an overdose,” he said. “But until the families report it, there is no certain way of knowing.” The doctors at the SMHS ATF have also noted other health implications. “Now we see people coming in with severe skin ulceration due to prolonged IV drug use,” Haq said. “Some of them are also diagnosed with endocarditis, which could lead to blocked arteries.”

Ahmad had been put on oral substitute therapy—a process in which opioid-dependent drug users are provided with long-acting opioid agonist medications—and was attending at least two counselling sessions every day. Unlike the experts in Baramulla, Rather believes OST is the only way for users to manage their addiction. “Counselling is important, but it’s not possible to stop using heroin in one go,” he told me. “That’s why we put them on OST. It helps gradually reduce heroin dependency.” He noted, however, that OST is not an assured cure for addiction and that he sees many of his patients returning for help after being off heroin for months. “You can only do so much, but, after these users return to their homes, it all depends on how they manage themselves,” he said. “Often, we have observed heroin is an escape for most of these users. But if we could have support groups in neighbourhoods, it will help to keep them motivated and give them a safe place.” Community support, though, is often in short supply.

Ayush, who wanted to be identified only by his first name, runs a chapter of Narcotics
Anonymous in Jammu city. NA is an international nonprofit that helps its members achieve and maintain abstinence by holding regular meetings in communities, so that users can share their struggles and experiences with each other. Ayush told me they do weekly meetings in Jammu but have not expanded into the Kashmir Valley. Ayush said that he is aware of the growing heroin addiction in Kashmir, but holding meetings in the valley would require users or former users to reach out to them. “That’s the rule,” he said. “Some invites we have received from Kashmir have either been from NGOs or health experts, who want to be part of these meetings. We don’t allow that.”

Apart from the easy availability of heroin, Rather told me, the ongoing mental-health crisis in Kashmir has in large part contributed to a spike in heroin consumption. “The allure of heroin is often linked to its ability to provide a sense of euphoria and escape from reality, which can be especially appealing to individuals who may be struggling with various psychological issues,” he said. “Most of them don’t have any idea of the highly addictive nature of heroin, which then leads them to a vicious cycle of drug use and mental health problems.” Jammu and Kashmir’s sociopolitical upheavals have greatly impacted the mental health of its population.

Counsellors attend to calls inside a dedicated phone-in counselling centre at Kashmir’s only major hospital for mental illness, IMHANS, in Srinagar on 2 August 2023. Kashmir’s mental healthcare clinics depict invisible scars of decades of violent insurrections, brutal counterinsurgency and unparalleled militarisation. With little in the way of mental health facilities, many Kashmiris turn to drugs for comfort. MUKHTAR KHAN /AP PHOTO

Over the past three decades, Kashmir has been marred by conflict. Since 2010, the valley has witnessed several mass protests, with security personnel killing hundreds of civilians and injuring thousands. In 2019, the Indian government revoked the region’s semi-autonomous status and instituted a severe internet and communication ban, intensifying tensions and exacerbating the already prevailing sense of insecurity. Studies reveal high rates of depression, anxiety and trauma in Kashmir, with substance abuse being a coping mechanism. The only noticeable difference has been a shift in drug preference, from cannabis to heroin.

A 2015 study, conducted by Médecins Sans Frontières in collaboration with Kashmir University and IMHANS, revealed that almost half of the valley’s adult population was suffering from some kind of mental-health disorder, “with 41% exhibiting signs of probable depression, 26% probable anxiety and 19% probable Post Traumatic Stress Disorder.” The report added that thirty percent of Kashmiri adults use tobacco to cope with stress. Very few people reported using alcohol, cannabis or opioids, but the study notes that the responses on illicit substance use may not be accurate due to underreporting and social stigma.

Rather has recognised a pattern among teenagers and young adults getting addicted to heroin. Almost all of them take heroin for the first time under peer pressure, but they are often also dealing with depression, anxiety or trauma. Seema Batool Shah, a clinical psychologist who is part of a three-member team that runs the ATF in Anantnag, agreed with this assessment. She has observed signs of depression and anxiety in most heroin users. “The daily unrest in the region has given generational trauma to people in every part of the valley,” she told me. “Young people don’t even realise they are living with trauma until something triggers them. It could be disappointing results in exams or a failed romantic relation or in some cases lack of job opportunities. That’s when they start using opium or cannabis as a coping method.”

Even though the situation seems pretty grim, Shah believed there is a sliver of hope. “Compared to ten years ago, today, there is far less stigma among people about seeking treatment for mental health,” she said. “Psychiatrists are available in almost all district hospitals. We have to have the same approach for drug addiction. We have to treat it as a health issue and make treatment available to everyone.”  

AT THE ATF IN KULGAM, some ninety kilometres from Srinagar, Ishrat Mohiduddin, the on-duty psychologist, had completed 94 consultations on the day I met her. Outside her small office, young men stood in a line to get their OST medication. A couple of women stood in the corner, hiding their faces with shawls.

In the last two years, over sixteen hundred heroin users have sought treatment for addiction at the facility, with over twenty thousand consultations. While the overwhelming majority of people seeking treatment are men, Mohiduddin told me that nine women had come in for help to deal with heroin addiction. “A woman came to us with her parents,” she said. “She had started using heroin when she had moved to Jammu to attend coaching classes. She came in for a few consultations. Then her parents admitted her to a private de-addiction centre outside of the state.” Mohiduddin told me that a young couple, both in their early twenties, come to them for regular consultations. “The boy was addicted to heroin and, when he married, he started doing it at home and convinced his wife to try it.”

Mohiduddin believes there could be more women using heroin who are afraid to seek treatment for fear of being outed as an addict. “For women, we have realised, it is difficult to come here for treatment,” she said. “They fear being seen by relatives or friends. And, because there are mostly men here at the facility, it makes them uncomfortable.”

Seema Shah agreed. In over two years, she said, she has seen only two women come for treatment. “Almost a year ago, two women who had been using heroin came to us. But, after that first consultation, they never came back.” She added that, although the ATF tries to maintain its patients’ privacy as much as possible, there are multiple barriers for women seeking treatment. “Their family members might worry they could be seen by other people. There is also a possible lack of awareness.” 

Even for men, the short-staffed and underfunded medical system can do little apart from their usual regimen. The Kulgam and Anantnag ATFs only have out-patient departments. The patients seeking treatment for heroin are prescribed OST, which is provided at the facility. Only possible overdose cases or individuals suffering panic attacks due to heroin use are admitted for the day. “After consultation with the doctor and the psychologist, they are given medicine for a certain number of days,” Mohiduddin told me. “We record their contact information and call them or their family members for further consultations.” 

Schoolgirls hold placards during a protest against the use of drugs in Srinagar, on 8 August 2007. Hundreds of school children took part in the protest organised by the Youth Welfare Organisation. ADNAN ABIDI / REUTERS

The inefficacy of such a system is visible in cases like that of Shahid. A truck driver by profession, he was the only earning member of his family and awaiting the birth of his first child, three years ago. He had a lot on his mind and decided to relax with his friends one day. It was the first time he used heroin. Like his friends, he grew addicted. “For the first few weeks, they gave me heroin for free,” Shahid told me. “But then I couldn’t stop using it. I would feel pain all over my body if I wasn’t high.” He eventually sold his truck.

Sameena, his wife, was the first to notice. “He would come home and not talk to anyone,” she said. “And, when I would try to talk to him, he would often start a fight with me. His parents thought I was being a bad wife. They didn’t know he was using heroin.” After a lot of convincing, Sameena took Shahid to the ATF at the Pulwama district hospital, where doctors prescribed OST. But he never went back for a second consultation. He told me that some of the men in his village would often go to the ATF, but not with the intention of seeking a cure for their addiction. “When they don’t have the money to buy heroin, they get medicine from the hospital,” Shahid said. “They inject that to get the high.” Mohiduddin told me that they were aware some patients were misusing OST medication. “To deal with this problem,” she said, “we have replaced the previous OST drug with a new one, which doesn’t have the high many users are after.”

Shahid said that he had never used the OST medicine but acknowledged sharing needles with other men. He has tested positive for hepatitis C multiple times and knows fully well the risks of sharing needles. “I’m scared of going to a chemist to buy syringes,” he said. “So, I take it from other people.”

Mohiduddin and her team are actively engaged in conducting weekly awareness programmes in villages and schools, as well as maintaining a Facebook page to educate people about the dangers of heroin use. But there are limitations to what they can do. “Unlike in other states, we can’t start a needle distribution scheme that could cut down the risk of infection because it might be viewed as us promoting drug use,” she told me. “There are entire villages here in south Kashmir using heroin, but family members often don’t want to acknowledge for the fear of how society might see them.” They were understaffed to take on an epidemic of this proportion. A colleague who had left, after working alone for a month, worried her. “He was looking for better opportunities,” she said. “And here we have a lot of workload.”

Despite the uphill task at hand, health experts I spoke to remain hopeful. Back in Srinagar, Rather was working on a proposal to start a skill development programme for patients at the IMHANS. Various studies have showed that life skills training significantly reduced relapse rates among drug users. “It helps them in developing resilience and coping mechanisms to deal with stress, boredom and other factors that often function as a trigger for drug abuse, especially among young people,” he said. “It also helps promote social interaction.”

Mohiduddin was optimistic too. “Till very recently, there was a taboo around mental-health issue,” she said. “Families and individuals facing mental-health issue would hesitate to seek help. But that has completely changed now. At present, there is a psychiatric department in almost every district hospital in Kashmir. We need a similar approach for heroin addiction. We need to seek users as patients in need of help and not treat them as criminals.” The cost of failure loomed over each of our conversations. Rather spelt it out. “If we don’t take steps now, an entire generation of young people would be lost to drugs.”

Reporting for this story was made possible by the Médecins Sans Frontières (MSF) Without Borders Media Fellowship. MSF, also known as Doctors Without Borders, works with journalists to encourage independent, impartial, and neutral reporting on health and humanitarian crises.