Prescription Drug Addiction in India: Opioids, Pregabalin, Benzodiazepines and the Silent Crisis No One Talks About

Prescription drug addiction in India is not a crisis that looks like the ones we imagine. There are no dark alleys. There are no strangers. There is a strip of capsules in a drawer, a refill that became routine, a pill taken to get through the board exams that turned into something that could not be stopped. This is the reality of prescription drug addiction in India today, and it is growing quietly inside homes, hostels, offices, and clinics that are supposed to be places of care.

The drugs involved are legal. Many are genuinely useful medicines. Tramadol is a painkiller. Pregabalin treats nerve pain and epilepsy. Alprazolam manages anxiety. Codeine cough syrups suppress irritating coughs. The problem is not the medicines themselves; it is what happens when they are misused, over-prescribed, taken without proper supervision, or sought out specifically for their mood-altering effects. Understanding prescription drug addiction in India requires looking honestly at the medicines, the system that distributes them, and the people who end up dependent on them.

These numbers represent a real and growing public health issue. The NDDTC-AIIMS National Survey of 2019, the most comprehensive of its kind in India, found that roughly 1 percent of Indians aged 10 to 75 had misused pharmaceutical opioids in the past year alone. That is a conservative estimate, because survey-based data underrepresents stigmatized behaviors. The actual number is almost certainly higher.

What Is Prescription Drug Addiction? Understanding Dependence vs. Misuse

The terminology matters here, because many people in India do not recognise that what they are experiencing is addiction. They see it as taking their medicine. The distinction between physical dependence, tolerance, and addiction is important to understand before anything else.

Physical Dependence vs. Addiction: Not the Same Thing

Physical dependence means the body has adapted to the presence of a drug and will produce withdrawal symptoms if the drug is stopped suddenly. This can happen even with correct, medically supervised use. A person who has taken a benzodiazepine every day for six months under a doctor's care is physically dependent on it. That dependence is a biological reality, not a moral failing, and tapering off with medical guidance is the appropriate response.

Addiction involves additional layers: a psychological compulsion to use the drug, loss of control over how much is taken, continued use despite knowing it is causing harm, and often a pattern of hiding the use from others or going to significant lengths to obtain more. Addiction frequently has dependence as a component, but dependence alone does not equal addiction.

Misuse vs. Abuse: How It Starts in India

Misuse and abuse are related but distinct. Misuse covers a wider range of non-prescribed use — taking a medicine prescribed to someone else, doubling a dose because the prescribed amount is not working, or continuing a prescription that a doctor would not renew. Abuse refers specifically to taking a substance for its psychoactive effects, the high, the sedation, or the altered mental state, rather than for its therapeutic purpose.

In India, the journey from prescribed use to misuse to dependence often happens without any single dramatic moment. It happens incrementally, and it happens to people who had no intention of becoming dependent on anything. That is what makes it different from what most people imagine when they hear the word addiction.

How the Brain Gets Hooked: The Science of Prescription Drug Addiction

Prescription drug addiction is not a weakness of character. It is a predictable neurological outcome of repeated exposure to certain molecules. Understanding why some drugs carry such high addiction potential helps explain why prescription drug addiction can happen to anyone who takes these substances long enough, and at high enough doses.

The Role of the Brain's Reward System

The brain has a reward circuit, centered on a region called the nucleus accumbens and the neurotransmitter dopamine. This system evolved to reinforce behaviors essential to survival, such as eating, bonding, and reproduction, by releasing dopamine and producing a sense of pleasure or relief. Addictive substances hijack this system by triggering dopamine release far beyond what natural rewards produce.

Opioids do this by binding to mu-opioid receptors in the brain, producing both pain relief and euphoria. Benzodiazepines enhance the activity of GABA, the brain's primary inhibitory neurotransmitter, producing sedation and anxiety relief. Pregabalin and gabapentin work on calcium channels in neurons, producing a calming and euphoric effect similar to alcohol. Each of these mechanisms, when triggered repeatedly, leads the brain to recalibrate its baseline. The brain starts to need the drug simply to feel normal.

Tolerance: Why More Is Never Enough

As the brain adapts to the continued presence of a drug, it becomes less sensitive to it. The same dose that produced relief or pleasure initially no longer has the same effect. This is called tolerance. The person needs more of the drug to achieve the same outcome. For someone managing genuine pain or anxiety, this means returning to the doctor for a higher dose. For someone misusing a drug, it means seeking larger quantities through whatever means available.

Tolerance develops at different speeds for different drugs and different people. It can develop within weeks for opioids and benzodiazepines, and sometimes faster in individuals who are younger, under chronic stress, or have a history of other substance use.

Withdrawal: The Biological Trap

When someone who is physically dependent stops taking a drug suddenly, the body reacts to its absence. Withdrawal from opioids produces intense flu-like symptoms, muscle cramps, severe anxiety, insomnia, and in some people, suicidal ideation. Withdrawal from benzodiazepines is one of the most medically dangerous withdrawal processes that exists, potentially producing life-threatening seizures if not managed properly. Pregabalin withdrawal produces anxiety, insomnia, nausea, sweating, and in some cases seizures as well.

The experience of withdrawal is one of the most powerful drivers of continued use. The person is not using the drug because they want to anymore. They are using it because stopping feels physically and psychologically unbearable. This is not a choice in any meaningful sense. It is a biological reality that requires medical intervention to manage safely.

The Most Commonly Misused Prescription Drugs in India

India's prescription drug misuse problem does not look the same everywhere. In Punjab, pregabalin has become so widespread it has acquired the street name "Budweiser" for its alcohol-like intoxicating effects. In Uttarakhand, codeine-containing cough syrups are misused by adolescents. In urban metros, benzodiazepines like Alprazolam are increasingly combined with alcohol for a more intense effect. Here is a detailed look at each major category.

1. Opioids — Tramadol, Codeine, and Tapentadol

Prescription drug addiction disrupts families across India, often beginning with a legitimate medical prescription that no one expected would become a source of dependence.

Opioids are the most misused class of prescription drugs in India by volume. The NDDTC-AIIMS survey found that pharmaceutical opioids accounted for a substantial share of the country's drug use disorder burden. Unlike the opioid crisis in the United States, which was driven by synthetic fentanyl and long-acting oxycodone, India's pharmaceutical opioid problem is centered primarily on tramadol, codeine, and more recently tapentadol.

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  TramadolA synthetic opioid prescribed for moderate to severe pain. In India, it was classified as a psychotropic substance under Schedule H of the Drugs and Cosmetics Act. It is widely misused for its euphoric and stimulant-like effects, particularly among truck drivers, manual laborers, and young men in Punjab, Haryana, and UP. Tramadol dependence develops rapidly, often within weeks of regular use. Seizures are a serious risk during withdrawal and at toxic doses.
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  Codeine Cough SyrupsCodeine is an opioid included in many over-the-counter cough preparations sold in India. When consumed in large quantities, it produces a sedative, opioid-like effect. Cough syrup abuse, especially in adolescents and young adults across North and Northeast India, is well-documented. Because these syrups are cheap, readily available, and do not attract the same social stigma as illegal drugs, they serve as a gateway to harder opioid use for many young Indians.
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  TapentadolA newer opioid painkiller that is stronger than tramadol and is increasingly being misused across Karnataka, Tamil Nadu, and other southern states. Police in Tumkur, Karnataka, seized over 1,700 tablets in a single crackdown in December 2024. Tapentadol is informally considered a stronger version of tramadol and is used by people with existing opioid tolerance. The government is currently considering bringing tapentadol under stricter Schedule X controls due to rising misuse.

2. Benzodiazepines — Alprazolam, Diazepam, Clonazepam

Benzodiazepines are a class of sedative medications prescribed for anxiety disorders, panic attacks, insomnia, and certain neurological conditions. In India, the most commonly misused benzodiazepines are alprazolam (Alprax, Restyl), diazepam (Calmpose, Valium), and clonazepam (Clonaz, Lonazep). These drugs are listed under Schedule H, meaning they technically require a prescription, but enforcement is patchy and many are dispensed without one, particularly in smaller towns and rural areas.

Benzodiazepine misuse in India is growing, particularly in urban centers. Research published in 2024 flagged alprazolam as a potential drug of major concern in India's near future, noting its pharmacological profile, wide availability, cultural tendency toward long-term prescribing, and increasing diversion for non-medical use. The fact that many people start using benzodiazepines under genuine medical advice makes it harder for them, their families, and even their doctors to recognise when use has crossed into dependence.

A particularly dangerous pattern documented in Indian metro cities involves mixing benzodiazepines or sleeping pills with alcohol. A clinical observer from Mumbai quoted in recent reporting described this combination as potentially lethal due to its combined suppression of the central nervous system. Both benzodiazepines and alcohol are CNS depressants, and their combined effect on breathing can be fatal at relatively modest doses.

3. Pregabalin — India's Fastest-Growing Prescription Drug Crisis

Pregabalin is a gabapentinoid, a drug class that works on calcium channels in the central nervous system. It is legitimately prescribed for neuropathic pain, epilepsy, and generalized anxiety disorder. It produces a calming, sedative, and mildly euphoric effect that people have described as similar to alcohol — which is precisely why it has acquired the street name "Budweiser" in Punjab.

A study published in 2024 from a North Indian addiction treatment centre found that pregabalin dependence accounted for 3.58 per 100 registered patients, with a median daily dose of 1,200 mg — roughly eight to twelve times the standard therapeutic dose. In Kashmir, a separate study found pregabalin abuse prevalence of 11.3 percent at a de-addiction centre, noting a clear shift from traditional opioid use toward pharmaceutical drugs, especially during periods of heroin shortage.

4. Sleeping Pills and Sedative-Hypnotics — Zolpidem, Nitrazepam

Sedative-hypnotics prescribed for insomnia, including zolpidem (Stilnox, Zolfresh) and nitrazepam, are misused both for their sleep-inducing effects and for the drowsy, dissociative state they produce at higher doses. In India, insomnia is massively under-treated, and when a doctor finally prescribes a sleeping pill, patients are often not informed that these medications are intended for short-term use only and carry significant dependence potential. Many end up taking them nightly for years without any review from their doctor.

5. Prescription Stimulants — Methylphenidate and the ADHD Conversation

Prescription stimulants like methylphenidate (Ritalin) are used to treat ADHD in India, though diagnosis and prescription rates for ADHD remain far lower here than in Western countries. Where these drugs do appear in the misuse landscape, it is typically in the context of students seeking cognitive enhancement during exam periods, or individuals combining them with other substances. This category is currently less prevalent in India's prescription drug misuse data than opioids or sedatives, but warrants monitoring as ADHD diagnosis and treatment becomes more common.

Prescription Drug Addiction in India's Students: Exams, Pressure, and a Very Quiet Crisis

The pressure of board exams, JEE, NEET, and competitive entrance preparation has created conditions where prescription drug misuse among Indian students is rising with little public acknowledgment.

The conversation about prescription drug addiction in India rarely focuses on students, even though young people are among the most vulnerable groups. The academic pressure that characterises Indian school and college life, particularly in Class 11 and 12 and during competitive exam preparation, creates a set of conditions that make prescription drug misuse more likely and more dangerous.

How Students Get Trapped — The Specific Pathways

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  Anxiety medication used as a crutch during examsA student develops severe exam anxiety. They see a doctor, who prescribes a short course of alprazolam or clonazepam. The medication works. The anxiety retreats. The exam passes. But the student, now aware of how effective the pill is, reaches for it again before the next high-stakes moment. This becomes a pattern. Within months, they cannot sit in an examination hall without taking one first. Then they cannot sleep without one. Then they cannot manage a regular day without one.
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  Sleeping pills for "studying all night"Zolpidem and nitrazepam are sometimes used by students not to sleep but to crash quickly after an all-nighter and recover before the next revision session. The logic is that a few hours of drug-induced deep sleep after studying all night will be more effective than lying awake for eight hours. The problem is that this pattern rapidly establishes dependence, and the quality of sleep produced by sedative-hypnotics is inferior to natural sleep in ways that actually impair memory consolidation and learning.
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  Codeine cough syrup as a cheap accessible highIn many parts of India, particularly in states like Uttarakhand, Himachal Pradesh, and across the northeast, adolescents use codeine-containing cough syrups recreationally. These are relatively inexpensive, available from many chemists without a prescription in practice, and socially less visible than drinking alcohol or smoking. Codeine is an opioid, and its misuse in adolescence is associated with a significantly elevated risk of developing opioid use disorder in adulthood.
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  Sharing prescriptions within peer groupsA student who has been prescribed a benzodiazepine shares it with a friend who is also anxious before an exam. That friend finds it helpful, asks for more, and eventually obtains their own prescription or buys the medicine without one. This pattern of prescription sharing is common and largely invisible to the healthcare system.
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  Pregabalin misuse in coaching hubsIn cities like Kota, where tens of thousands of students prepare for JEE and NEET under extreme pressure, reports of pregabalin misuse among students have emerged. Pregabalin's accessibility, its ability to reduce anxiety, and its euphoric effects at higher doses make it particularly attractive in high-stress environments where official mental health support is minimal.

The Over-Prescription Problem: How the Healthcare System Contributes to Prescription Drug Addiction in India

It would be incomplete to discuss prescription drug addiction in India without examining the role of the healthcare system in creating and sustaining it. Doctors are not the villains in this story. Most prescribe these medications because they genuinely help, and because the alternatives, adequate psychotherapy, structured pain management programs, or non-pharmacological insomnia treatment, are either not available, not affordable, or take considerably more time than a brief consultation allows. But the systemic conditions that surround prescribing in India do create vulnerability.

The Three-Minute Consultation

The average consultation time with a general practitioner or even a specialist in India's public health system is often between three and seven minutes. In that window, a doctor is expected to take a history, examine the patient, review any tests, make a diagnosis, and explain the treatment plan. A patient presenting with sleep difficulties, anxiety, or chronic pain in that context is likely to leave with a prescription. There is simply not enough time to explore non-pharmacological alternatives, to assess addiction risk, or to discuss the limited duration of use that sedatives and opioids require to be safe.

Lack of Prescription Monitoring Systems

India does not have a national prescription drug monitoring programme comparable to those in the United States or the United Kingdom. This means a patient can visit multiple doctors, collect multiple prescriptions for the same controlled substance, and have them filled at different chemists, with no single system flagging the pattern. Doctor shopping, the practice of visiting several doctors to obtain multiple prescriptions, is a well-documented consequence of this gap. Dr. Atul Ambekar of NDDTC, AIIMS has publicly confirmed that patients often seek medical help to quit tapentadol and pregabalin after prolonged misuse, confirming these are genuine clinical presentations in Indian addiction medicine.

Chemists Dispensing Without Prescriptions

Schedule H drugs technically require a valid prescription in India. In practice, many pharmacies and chemists dispense these medicines to regular customers without one, particularly in smaller towns and in chemist shops attached to or near clinics. The regulatory gap around pregabalin until recently is a striking example: because it was not on Schedule H1, no prescription record was required at all. Large-scale seizures of pregabalin from licensed chemists in Punjab in 2023 underline the extent to which commercial distribution networks profit from misuse.

The Mental Health Care Gap That Drives Over-Medication

India has a documented shortage of mental health professionals. The psychiatrist density is approximately 0.3 per 100,000 population. When someone with a severe anxiety disorder or chronic insomnia cannot access evidence-based psychological therapy because there are no trained therapists in their district, medication becomes the default response. The problem is not that doctors reach for the prescription pad. It is that the prescription pad is often all they have to offer, and the system has not invested sufficiently in the alternatives.

Signs and Symptoms of Prescription Drug Addiction in India to Watch For

The signs of prescription drug addiction vary depending on the drug class involved, but there is significant overlap. What follows covers the most important behavioral, physical, and psychological indicators, mapped to the drug categories most relevant in India.

Behavioral Signs Across All Categories

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  Taking medication in larger amounts or more often than prescribedThe prescription says one tablet at night. The person is taking two or three. They run out before the month ends and find ways to get more from multiple sources.
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  Unable to function without the medicationThey describe being unable to work, eat, sleep, or be in a social situation without first taking the drug. The medicine has become a prerequisite for daily life rather than a therapeutic tool.
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  Continuing to use despite knowing it is causing problemsThey know the medication is affecting their memory, their relationships, or their work performance, but they cannot or will not stop. When they try, the physical and psychological distress of withdrawal drives them back.
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  Doctor shopping or obtaining medicine without prescriptionVisiting multiple doctors for the same medication, or purchasing it from pharmacies without a prescription, or obtaining it from others who have been prescribed it.
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  Hiding the amount usedDiscarding packaging, hiding strips of tablets, or being vague or dishonest about how much of a medication they are using when asked by family or by a doctor.

Physical Signs by Drug Class

Who Is at Risk of Prescription Drug Addiction in India?

Prescription drug addiction can affect anyone who is exposed to these substances long enough and in sufficient doses. But certain factors do increase vulnerability, and in India, some of these factors are particularly prevalent or carry unique cultural dimensions.

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  Individuals with untreated mental health conditionsAnxiety, depression, PTSD, and chronic stress significantly increase the risk of prescription drug misuse. When mental health conditions go untreated — as they do for the vast majority of affected Indians due to access and stigma barriers — people self-medicate with whatever provides relief, and prescribed sedatives and painkillers fit that role readily.
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  People in chronic painLegitimate chronic pain conditions, including diabetic neuropathy, back pain, arthritis, and post-surgical pain, require sustained pain management. In India, where structured multi-disciplinary pain clinics are rare outside a handful of major cities, opioid and pregabalin-based prescribing for pain is often the primary treatment offered, creating risk of long-term dependence.
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  Adolescents and young adultsThe developing brain is significantly more vulnerable to the neurological effects of addictive substances. Research consistently shows that earlier onset of use is associated with higher likelihood of developing addiction. In India, where academic pressure begins early and peaks in the mid-teens, adolescents are exposed to the conditions that make prescription drug misuse appealing at exactly the stage when their brains are most susceptible to its effects.
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  People with a personal or family history of addictionGenetic factors account for roughly 40 to 60 percent of the variance in addiction risk. Someone with a parent or sibling with an alcohol or substance use disorder carries elevated biological vulnerability to developing one themselves. This is not a certainty but is a factor worth being aware of when prescribing or taking addictive medications.
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  Low-income groups and manual laborersThe NDDTC-AIIMS data as well as published research on opioid use in India consistently identify socioeconomic stress, manual labor, low income, and unemployment as significant risk factors. Long-distance truck drivers in India have notably high rates of tramadol use, where the drug's stimulant-adjacent effects are used to manage long shifts, exhaustion, and chronic musculoskeletal pain.
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  Individuals who were not counseled about addiction risk at time of prescriptionResearch repeatedly shows that patients who are clearly informed at the time of prescribing that a medication carries dependence potential, has a limited safe duration of use, and should not be combined with alcohol are significantly less likely to develop problematic use. In the short consultations that characterize most of India's healthcare encounters, this counseling rarely happens adequately.

How to Get Help for Prescription Drug Addiction in India

The most important thing to understand about getting help for prescription drug addiction in India is that this is a medical issue and it requires medical support. Trying to stop benzodiazepines or opioids abruptly at home is not just difficult; for some drugs and some levels of use, it is genuinely medically dangerous. Seizures, severe psychiatric episodes, and cardiovascular complications are real withdrawal risks. The path to recovery for prescription drug addiction requires professional involvement.

Medically Supervised Detoxification

The first step for someone with established physical dependence is medically supervised detox. For opioids, this involves a gradual taper, often using buprenorphine or methadone as part of Opioid Substitution Therapy (OST), which the NDDTC-AIIMS has helped scale across India through government-NGO partnerships. For benzodiazepines, the protocol involves a very slow, structured taper of the drug itself, since abrupt cessation carries seizure risk. This cannot be safely managed at home without medical supervision.

Government hospitals, particularly AIIMS in New Delhi, NIMHANS in Bangalore, and state mental health institutions, offer addiction treatment services that include detox. Many private hospitals in metro cities also have de-addiction units. Waiting times at government centres can be long, but services are significantly more affordable.

Psychological Support — The Part That Makes the Difference Long-Term

Medical detox removes the physical dependence. What it does not do is address the underlying reasons the person became dependent in the first place, the anxiety, the pain, the stress, the habit patterns, or the social environment that enabled the use. Without psychological support, relapse rates are high. Evidence-based psychological therapies that are relevant to prescription drug addiction include Cognitive Behavioral Therapy for substance use disorders, Motivational Enhancement Therapy, and family-based interventions, all of which can be provided by a trained clinical psychologist.

At Vaishalya Healing in Palampur, we work alongside medical teams to provide the psychological support component of recovery: helping individuals understand the roots of their dependence, build coping skills for the situations that previously drove their use, and rebuild lives and relationships that addiction has damaged. This is not separate from the medical part of treatment. It is what makes it last.

Support Resources Available in India

Myths About Prescription Drug Addiction That Keep Indians from Getting Help

Leena Mehta

Counselling Psychologist  •  Vaishalya Healing, Palampur

Leena Mehta is a counselling psychologist with over 5 years of experience in private practice and rehabilitation support across Himachal Pradesh. She holds a Postgraduate degree in Psychology, a PG Diploma in Guidance and Counselling, and an APA-certified online training credential. Through Vaishalya Healing, she works with individuals, couples, and families on anxiety, relationship challenges, de-addiction support, and emotional well-being, both in person and virtually.

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