The present paper reports on IDU among children using substances from a large-scale study conducted across 100 cities in various states and regions of India. Among the sample recruited for the study (n = 4024), a high proportion (12.1%) reported current (1 month) use of injecting drugs and 12.6% reported ever injecting drugs. People who inject drugs are often described as “hard to reach” population and within this, the children and adolescents using IDUs are almost “invisible.”

To the best of our knowledge, this is the first study that has researched children using substances in a nationwide effort. Further, it included children from various settings: those living at home (schoolgoing: 34% and out of school: 54%) and those living on streets (12%), either alone/with families. Use of injections was reported by substance-using children across majority of states/UTs of India and not only restricted to the northeastern region.

It is important to emphasize at the beginning that the study did not aim to assess the prevalence rates of IDU in younger population across India, and consequently, the figures available from the study findings should not be interpreted as the prevalence figures. Rather than focusing on prevalence, we employed alternate sampling methods (e.g., snowball technique) which would help to tap into an otherwise “harder-to-reach” subgroup population to document their profile and pattern of substance use.

IDU clearly places individuals at a high risk of acquiring HIV and hepatitis C virus and of experiencing other harms such as overdose. Injecting drug use among children can be a serious public health problem for any country and underscores the urgent need to intervene and protect this vulnerable group from falling prey to HIV.[1011] The sample had the onset of IDU at an average of 1–1.5 years before the current assessment. It appears that almost all children who initiated IDU continued to use it. Further, the average number of days per month for which the sample reported the use of IDUs was 16 days per month, pointing to a frequent, risky pattern of use. It has been seen from various international studies that risk of becoming HIV infected is especially high during the period immediately following the initiation of injection (within the first 1–2 years). There is, thus, only a brief “window of opportunity” to intervene and prevent infections among this child population.[1112]

IDU was more commonly reported by those living at home compared to street sample. This finding is most likely due to sampling bias toward the child substance users living at home. Those using harder substances are likely to be the “known substance users” in their neighborhood, and probably, had more chances to be included in the study by the NGO working in that area. In contrast, those using licit substances at homes may be able to hide their substance use and had less likelihood to be contacted for the study inclusion. This may have also led to a higher proportion of IDUs in this sample. Street sample in this study more often preferred the use of inhalants, which could be because they are easily available, accessible, and cheaper. It is in consonance with previous studies on street children in New Delhi and Bengaluru.[1314] It is also to be noted that among those street children who had IDU, they initiated injection use more than a year earlier (14.0 ± 2.0 years) compared to those who were schoolgoing (15.5 ± 1.1 years) and out of school (15.26 ± 1.3 years), pointing to a subsample of street children in whom IDU makes an earlier onset. Regarding average time from the first drug use to initiation of injections, there was an interval of about 3 years from the initiation of tobacco to the initiation of IDU in this sample, which is a potential time for preventive interventions for IDU initiation.[15]

Family factors such as parental substance use, physical abuse, and poor quality of relationship between parents and children is a known risk factor for substance use among children as seen in international studies.[16] Presence of substance use in another family member may act through a variety of mechanisms such as by increasing genetic risk or by negative role modeling to increase a child's susceptibility to substance use. Childhood sexual abuse places a higher risk for initiating injection use among substance users.[17] Further, substance use in a family member often leads to familial quarrels or discord, poor supervision of the children, lack of parental involvement in child's activities, and may pose several other environmental risk factors for the child, for example, easy availability of substance. Many of these well-established risk factors for child substance use are also prominent in the present study sample. Nearly 56% of the sample also reported the presence of substance use in a family member and 43% reported frequent familial quarrels and being beaten/abused by family members. Poor family bonding and attachment to parents has been linked to increase in the likelihood of substance use in children, while close emotional ties with parents is a protective factor for substance use.[1618]

The most powerful of the social influences for substance use at a younger age is that of peer influences. The association with the peers who approve the use of substances or use substances themselves predisposes a child to substance use.[1619] In this study, more than 76% of IDUs had a close contact with friends who use substances. From the perspective of prevention, it is important to impart the basic skills to children such as resisting peer pressure and being assertive to say “no” when offered substances by peers. An enhanced contact with the nonsubstance using friends is often recommended as part of the treatment process for the children using substances.

A significant proportion of the sample engaged in risky sexual behaviors, including sex in exchange for money/drugs. The presence of substance abuse in a child may facilitate, in some ways, the involvement in sexual behaviors, for example, impaired decision-making or disinhibition may occur under the influence of a substance, which may make a person more likely to indulge in sexual behaviors. As the study was cross-sectional, it might be difficult to comment about the directionality of the association. The association between early-onset substance use and involvement in sexual behaviors has been observed in previous studies.[2021] Nearly 10% of the present sample of IDUs comprised female children/adolescents. In a previous Indian study on adult female IDUs, a significantly higher proportion of female IDUs were uneducated, unemployed, worked as sex workers, and switched to injecting drug use faster as compared with male IDUs.[22] These high-risk sexual behaviors represent an additional risk for developing and transmitting HIV. Injection substance use also has a possible link with mental health, as seen in literature including an association with suicide attempts.[23] Mental health needs of this subpopulation often remain neglected and may contribute to continuing substance use. In this sample, nearly 60% of children with IDU reported sadness/anxiety and a stressful life, pointing to a need to pay more attention to the associated psychological symptoms from a preventive and management perspective, as a risk factor or as a consequence of persistent substance use.

Nearly half of the children acknowledged that they have a problem with regard to substance use. No quit attempt was made by 52.5% children, but nearly 18% of the children attempted quitting less than a month back, and quit attempts were made at some point by half of the sample. Every IDU child should have suitable access to treatment and support. The tremendous benefits of provision of treatment services to children in short- and long-term justify the support, development, and investment in programatic responses. Protecting children from potential harms of IDU must be at the forefront of concerns when developing or strengthening and scaling national programs. During planning, it is of utmost importance to ensure that children who inject drugs are also covered under the gamut of services. In a systematic review, the peer-based behavior modification and addiction treatment interventions were found to be most effective in younger people to reduce the risk of initiation of injecting drugs.[15] It is crucial that the targeted intervention sites with IDUs should review their existing policies to include child population below 18 years of age for a diverse range of harm reduction services, which are currently limited to adult age groups. With emerging evidence that the age of initiation of IDU is low and/or decreasing, there is a need to reconsider these age restrictions for maximal benefit. Recently, after gaining more evidence for safety, buprenorphine substitution is now being offered to adolescent IDUs which is a welcome step.[24] Adopting a flexible approach would enable these services as a first point of contact with IDU children and possibly a link to connect them with drug treatment services.

Given the hidden nature of the IDU population, it is extremely challenging for service providers to identify and reach them for services. The study used a mix of recruitment methods which was successful to identify child IDUs in the current study. The similar approach can be used for enrollment for an intervention, which will allow for IDUs with different demographic characteristics and risk profiles to be enrolled for intervention as and when they are implemented.

The study findings counter the popular perceived belief that the injecting drug use problem was mainly concentrated among adult males and was limited to northeastern region only.[2526] Although the worst-hit site appeared to be from Mizoram, this study was able to identify children who were currently injecting drugs from most other states and regions in India. Unlike past, the IDU in adult population too have spread outside northeastern region with emerging epidemics to southern and northern states.[2728]

The study findings are subject to some limitations. The main focus of the study was on the pattern and correlates of children using substances, therefore information pertaining to some other details/factors specific to IDU behavior was not collected, including the circumstances around IDU initiation, sharing practices, and kinds of drugs injected. A previous Indian survey on adult IDUs found pharmaceutical opioids and heroin to be the most injected drugs,[29] which might be present in younger population too although these details were not specifically gathered in the present study. Second, the survey used a convenience sample and consequently nonrepresentative for the entire population. However, the present study did not aim to assess the prevalence rates of IDU in younger population, rather sampling methods which would facilitate penetration into this “hard-to-reach” and “invisible” population were employed in an effort to document the presence of IDU in children. Children were sampled through mixed methods and it was unknown how deep this approach penetrated the subpopulation at the study sites; it may be possible that who were not recruited had different characteristics to the study participants.

In future directions, there is a need for more comprehensive research among newly initiated young IDUs so that early intervention and prevention programs may be implemented. There is a need to target harm reduction messages for IDU to younger age group children who use substances. Strategies need to be devised specifically for young IDUs to reduce the impact of injecting drug use on the HIV epidemic in India, especially as adolescents may have lesser awareness about risks and may have a lower harm perception or higher risk-taking behaviors. Routine surveys should include the child and adolescent population, and more qualitative studies should be undertaken for better, in-depth understanding.