Theraverse . June 3, 2024

In India, alcoholism has for long been a topic of much national contention and controversy befitting the nature of its complexity that is not merely influenced by neurobiological and psychosocial factors but also political, religious and geographical factors particularly in a country and people as diverse as India. India constitutes a significant proportion of the world population and changes in Indian statistics influence overall world statistics. New statistics on increased alcohol consumption have made the public, doctors, researchers and hopefully policy makers sit up and pay attention to the direction in which we seem to be heading.

The National Mental Health Survey 2015-2016 reported a prevalence rate of 4.6% for alcohol use disorders. Meanwhile a study published in The Lancet reported that India’s annual alcohol intake in terms of volume had increased by 38% between 2010 and 2017, that is, from 4.3 to 5.9 litres per adult per year¹.  While the volume per adult is still lower than U.S or China, the increase over 7 years has been significantly more in India. This was reflective of the overall finding that intake has been growing in low- and middle-income countries, while the total volume of alcohol consumed in high-income countries has remained stable. Despite such data making its way to the fore, India continues to remain deficient in terms of manpower, resources and policies targeted towards managing this burgeoning public health crisis. Alcohol dependence is not only by itself a public health crisis but has far reaching impact on many other diverse phenomena ranging from intimate partner violence, law and order related problems to the prognosis of a plethora of medical conditions given that alcohol dependence  also frequently  turns out to be a barrier to overall treatment adherence. For example, in a population-based study conducted in the southern state Kerala, treatment outcomes among MDR tuberculosis patients consuming alcohol was found to be poor compared to those who did not consume alcohol².

Even in times such as the recent global public health crisis caused by the corona virus outbreak and the prevailing nationwide lockdown in India, newspapers were highlighting the effects of the lockdown on alcohol dependent individuals due to the sudden unavailability of alcohol following the lockdown. One state (Kerala) passed a government order stating that those with severe alcohol withdrawal symptoms could receive prescriptions from doctors to get special passes from the state’s excise department to obtain alcohol. This decision was taken in view of emerging reports of suicides by patients suffering from severe withdrawal symptoms. However following protests by doctors, a case was filed in the high court seeking a stay on the government order which was subsequently stayed. In the neighbouring Tamil Nadu, there were reports of people drinking aftershave lotion and losing their lives due to unavailability of alcohol. There were also reports of massive burglaries targeting local wine shops leading to the state government ordering all shops in remote areas to move alcohol stocks to centralised storage areas or marriage halls with police protection. It is therefore possible to imagine the myriad negative public health and social repercussions of prevailing alcohol use disorders.

To formulate effective strategies and solutions which is but a beginning, one needs to understand the problem in India in all its complexity as well as in its varied contexts which by itself presents a challenge in view of the diverse political, social, economic, geographical, ethnic and religious factors and their interactions manifest here. Understanding the profile of the average Indian drinker might well be a befitting beginning. The stereotypical Indian alcoholic is a male in his fourth or fifth decade, likely a skilled labourer belonging to a lower socio-economic class with family history of alcohol dependence who probably started drinking in early adulthood, often because he felt tense or tired after work and gradually grew dependent over the course of a few years. Meanwhile marriage, fatherhood and other such social transitions also occurred and not before long the individual found himself spending a great part of his total income on alcohol, neglecting his spouse and children, at times also his work, accumulating not just financial debts but also loss of reputation and good standing in society along with co-morbid health problems and eventually landing in the hospital or nearest available health facility with alcohol related health issues such as alcoholic liver disease. He says he did not consult a doctor earlier because he was unaware that alcohol dependence is a medical disorder that can be treated. While the average Indian drinker is often conceptualised as a male, this cannot undermine the fact that alcohol use disorders in women is on the rise and has made a steady albeit silent contribution to the overall increase in consumption. Although the official WHO statistics for prevalence of alcohol use disorders in Indian women is only 0.5% (in men it is 9.1%), there is likely under reporting and the actual figure is probably higher and also unequally distributed in geographical clusters. For example, a cross-sectional study done at a medical college in Goa over a period of two months reported that the prevalence of alcohol consumption per se was higher in women (40.6%) as compared to men (38%)³. Increasing social acceptance of alcohol as way to relax and unwind, media endorsement of drinking, alcohol’s use as a social lubricant, changing gender roles and evolving social and family structures in the traditionally patriarchal Indian society have been attributed to as playing a role. Terms such as “pinking” of the alcohol market have been used to describe the ongoing phenomenon.

Geographically too there is marked disparity in the prevalence of alcohol use in different states as revealed by the National Survey on Extent and Pattern of Substance Use in India conducted in 2018  with highest prevalence in states such as Chattisgarh (35.6%), Tripura (34.7%), Punjab (28.5%), Arunachal Pradesh (28%) and Goa (28%). This disparity is influenced by various factors including the local state alcohol policy such as presence of prohibition which in turn is often determined by the political climate. Overwhelming majority of users are in the age group of 18-49 years (74%). Nationally 2.7% of the population (2.9 crore individuals), that is, 18.5% of current users of alcohol are affected by alcohol dependence. However this proportion is much higher in states such as Puducherry, Punjab, Andhra Pradesh and Karnataka where more than 40% of alcohol users are dependent. Overall around 5.7 crore Indians need help for their alcohol use problems (harmful use or dependence) of who 75% are concentrated in 10 of the 28 states in the country.

Coming to treatment options which are still dismally inadequate, they usually follow the demand reduction line of approach and availability of treatment depends on the geographical location (urban metropolitan/ urban non-metropolitan/rural), availability of trained professionals , the socioeconomic status of the individual, (paid/ subsidised/ free services), and the types of centres or institutions present in the locality ( central or state government funded centres / Non-governmental organisations/ private institutions/ de-addiction centres/ public welfare trusts/ outpatient clinics). The central government body Ministry of Health and Family Welfare has established about 122 inpatient focused de-addiction centres(DACs) 43 of which are in north-eastern states through which it administers the Drug De-addiction Programme(DDAP)⁴. All the centres except the north-eastern ones received a one-time grant from the central government when being set up after which they were expected to be run by the state governments. DACs have also been set up in prisons to address the needs of prison inmates, huge number of who have SUDs. The programme is modestly funded (150 crore rupees was the approved budget outlay for 5 years in the 12^th 5-year plan from 2012 to 2017 and in most states there are no state-level counterparts for this programme. Due to shortage of psychiatrists, the main service providers are non-specialist cadre of general duty medical officers, paramedical and paraclinical professionals who have been trained through 7 day long training programmes and additional resource materials such as manuals and textbooks. The DDAP is accompanied by its sister programme –the Drug Abuse Monitoring system which was conceptualised to collect data from all the DACs on an annual basis. In addition, 25-20 drug treatment clinics (DTCs) were also added to the programme for period 2012-17 to offer outpatient services for all SUDs free of cost- both psychosocial and pharmacological, with plans for expansion of the initiative in future . This initiative was notably awarded the British Medical Journal South Asia Award  for the year 2016 under the “ Noncommunicable Disease Initiative of the Year” category.

While the Ministry of Health and Family Welfare focuses on treatment programmes, prevention activities are carried out by the Ministry of Social Justice and Empowerment and they comprise awareness and rehabilitation targeted programmes such as Workplace Prevention Programme, deaddiction camps and Integrated Rehabilitation Centres for Addicts (IRCAs).The government centres form but a part of the service delivery for SUDs, which is supplanted in large by a rather disorganised private sector comprising private medical practitioners, hospitals, private centres and NGOS.

However despite alcohol use disorders rapidly growing to be a massive public health challenge, especially in a population dense growing economy such as India, with diverse impact and far reaching consequences, efforts and strategies to manage and curtail the problem remain woefully inadequate. Being a research clinician doing her doctoral thesis in the genetics of alcohol dependence, this author has had opportunity to work closely with caregivers and families of patients suffering from alcohol dependence and therefore gained some experience and understanding about the ground level realities and challenges one faces in treating alcoholism in India. Taking a three pronged approach, one can segregate the problems to be overcome into those at the end of the treating professional, those at the patient’s end and also the problems embedded in the social system at large. As a treating professional, whether one is working in a government institution or in private practice some challenges remain universal. These include time constraints, partly due to administrative and other non-clinical work responsibilities, lack of adequate trained supporting personnel such as social workers who form the spine of rehabilitative services, inadequate financial resources, reduced pharmacotherapeutic options due to cost burden (for example, the cost of available naltrexone in the market remains prohibitive for a large segment of the population here in Tamil Nadu), inadequate referral services and at times an attitude of therapeutic nihilism due to repeated experiences of  unsuccessful treatment.

At the patient’s end, problems include lack of accessibility to appropriate treatment services, financial burden for those unwilling to utilise free government services due to convenience related, logistic or other reasons, illiteracy, lack of knowledge, loss of social prestige and lack of social support. In the society, stigma towards this disorder remains rampant and many individuals including a sizeable segment of medical professionals continue to believe it is a bad habit to be rectified or a character flaw that needs to be corrected rather than a disease that requires treatment and evidence based psychosocial interventions. Accordingly one comes across unethical practices such as lay persons running so called centres where patients are deposited often against their will by ill-informed family members for varying periods ranging from weeks to months and subject to cruel and inhumane treatment by untrained staff so that they may be “remedied and reformed”. Needless to mention, such centres are mostly unlicensed and run illegally. Government funding and allocation of resources remain inadequate.

Research is also underfunded and there is scarcity of institutions where there is adequate thrust on clinical research in addition to academics and clinical care. Not many clinicians dare venture more boldly into academic research due to lack of adequate training in research, shortage of time and paucity of decent resources and infrastructure for research. There is also the fact that there are unique challenges in conducting research in the substance dependent populations where rates of attrition and adequate social support are particularly high. Politics often determine policy and sometimes this is simply not based on health research findings and expert advice but instead on popular public sentiment and vote bank calculations. In states where there is prohibition in force for example, the prevalence of alcohol consumption is lower but there is higher illicit liquor production and consumption, black marketeering, barriers to treatment and also underreporting of alcohol use. Provisions to address these inevitable consequences are sparse. There is an alarming treatment gap for the disorder that is nowhere close to being bridged. According to the National Mental Health Survey of India (2015-12016), the treatment gap for alcohol use disorders is 86% as compared to that of other drug use disorders (73%). Only about 2.6% of the total alcohol dependent population receive any help for their problem and of this, interestingly, the largest contribution is help from religious/spiritual sources (33%) followed by a government doctor or health facility (25%). Just 1 in 38 Indians with alcohol dependence receives any treatment. The proportion receiving inpatient treatment is even smaller (National Survey on Extent and Pattern of Substance Use in India).

While as a country we remain mired in manifold drug use disorder problems and face political, economic, social and geographic limitations in tackling the same, emerging research study and survey findings, expert opinions and commentaries are slowly drawing attention to the silent, ongoing public health crisis. Both the central and state government need to sit up and pay heed to the writing on the wall. They need to start working in closer collaboration with each other in order for continuous and effective delivery of services to the target population. There needs to be more allocation of resources and funding and strengthening of the basic infrastructure. There should be more training as well as funding and incentives for conducting research in this field and more research centres need to be setup where treatment can be cohesively integrated with clinical research. A task force needs to be set up with representation from both the centre as well as the state, which involves a multidisciplinary team including policy experts, public health scientists, mental health professionals, administrators, health insurance company representatives, law and order specialists as well as patients and caregivers. This task force can concentrate on need of the hour recommendations for sound strategies to curb and treat alcohol use disorders at multiple levels of governance and healthcare. Public-private partnerships should be embarked upon in order to build capacity and improve services. Sensitisation needs to be started in schools and colleges facilitating prevention and early intervention. The workplace can also be utilised to enable service delivery. For example in corporate India, workplace programmes and interventions can be incentivised to enable better reach of awareness campaigns, reduce stigma and offer opportunities to approach for and receive proper treatment. The covid pandemic has been a lesson in understanding serious gaps and lacunae in our healthcare systems especially in times of unforeseen emergencies. We need to formulate better strategies in advance to handle substance dependent patients during times of disaster and crisis such as the ongoing one. Change is going to take some time in the coming, the earlier we start the better. For the cup runneth over and not in a good manner.

By Dr Navina Suresh MD

(Consultant Psychiatrist at the Talk Therapy Clinic)

References:

1. Manthey J, Shield KD, Rylett M, Hasan OS, Probst C, Rehm J. Global alcohol exposure between 1990 and 2017 and forecasts until 2030: a modelling study. The Lancet. 2019 Jun 22;393(10190):2493-502.

2. Duraisamy K, Mrithyunjayan S, Ghosh S, Nair SA, Balakrishnan S, Subramoniapillai J, Oeltmann JE, Moonan PK, Kumar AM. Does Alcohol consumption during multidrug-resistant tuberculosis treatment affect outcome?. A population-based study in Kerala, India. Annals of the American Thoracic Society. 2014 Jun;11(5):712-8.

3. Verenkar YJ, Vaz FS. Prevalence and pattern of alcohol consumption using alcohol use disorder identification test among students at a medical college in Goa, India. Int J Community Med Public Health. 2018 Jul;5(7):2935-8.

4. Dhawan A, Rao R, Ambekar A, Pusp A, Ray R. Treatment of substance use disorders through the government health facilities: Developments in the “Drug De-addiction Programme” of Ministry of Health and Family Welfare, Government of India. Indian journal of psychiatry. 2017 Jul;59(3):380.