Alcohol problem in Nepal

Indroducation Alcoholic beverages have been used by man since thousands of years and they also play an important role in many societies and cultures across the world. Ethanol or ethyl alcohol (C2H5OH) is the active ingredient in many alcoholic beverages including beer, whisky, vodka, gin, rum and so on. Alcohol is mainly absorbed unaltered from the stomach and small intestine. The presence of alcohol can be detected in the blood within 5 minutes after ingestion, and it reaches its peak concentration within 30 to 90 minutes. Alcohol is chiefly metabolized in the liver. Alcohol is a CNS depressant. Long term and regular use of alcohol is usually associated with much negative consequences-physical, mental, social, economic consequence. Alcohol use disorders are a major public health problem worldwide and in Nepal also, they are a major cause of morbidity and mortality. Some facts about alcohol are; • Alcohol use disorder are one of the 5 mental disorders in the list of 10 leading causes of disability world wide (WHO1999) • Alcohol (Ethanol) is absorbed unaltered from the gastrointestinal from the gastrointestinal tract and is 90% of it is metabolized in the liver. It is totally excreted and is not stored in the body. • It is a dependence producing substance and a CNS depressant. • Alcohol dependence disorder is chronic and relapsing disorder affecting physical, mental and social well being of any individual. It affects not only the individual but also his family and community. • Accepting drinking as a problem by the patient is an important first step, because most of the alcohol users deny tat they are dependent (denial) • Family environment affects the recovery process from alcohol use disorders. • Alcohol is the most comment substance used in Nepal and is the commonest cause of domestic violence and road traffic accidents. Causes of excessive alcohol use There if not a single causative factor. It usually results because of interaction of many factors. These factors include: Genetic factors: Adoption studies have shown that sons of biological parents who are alcohol dependent have a four times increased risk of alcohol dependence. Biochemical factors: Abnormalities in the enzymes metabolizing alcohol especially alcohol dehydrogenase and abnormalities in various neurotransmitter mechanisms, is suspected to predispose to the development of alcohol use disorder. Learning factors: learning from the drinking behavior of parents & peers may lead to a behavior of excessive alcohol use. Individual factors: Male sex widowed and single Personality factors: Contain personalities, especially those with antisocial personality and people with chronic anxiety with pervading sense of inferiority, are at more risk to developing alcohol dependence. Torture victims: Torture victims are at risk of developing alcohol dependence, because of the of various symptoms including hyper arousal, anxiety, Depression and phobias. Alcohol consumption in the society: The level of alcohol drinking in a society depends mainly on tree factors: Economic control: Price of alcohol significantly influences the drinking level in the society. Formal controls: Licensing laws, limited sale outlets, limited hour for sales, etc. influence the drinking level in the society. Informal controls: Rules dictated by the society, religion and the traditional / cultural norms regarding drinking greatly influence the of drinking in the society. Much mental and behavioral disorder can be caused due to use of alcohol, and these as the alcohol use disorder. Alcohol use disorders includes: Acute Intoxication This is a transient condition following administration of alcohol, resulting in disturbances n level of consciences, cognition, perception, affect or behavior or other psycho physiological function. It’s usually associated with high blood level of alcohol. This is a transient phenomena and the intensity of intoxication decreases with time. Their effects eventually disappear in the absence of further use of the alcohol. Recovery is complete unless there is any tissue damage or complications. Acute intoxication needs to be differentiated from head injury and hypoglycemia. Alcohol abuse Alcohol abuse also called “problem drinking”, is a pattern of excessive drinking that result in adverse health and social consequences to the drinker, and to those around the drinker. People with an alcohol abuse problem: • Use alcohol to help them change the way they fell about themselves and/or some aspects of their lives. • Experience some problems associated with their alcohol use • Get complaints about their alcohol use. • Lose internet in activities and hobbies that used to bring pleasure. • Get irritable as their usual drinking time approaches, especially if alcohol isn’t available. • Keep alcohol in unlikely places at home, at work and in the car. • Gulp drinks, become intoxication intentionally. • Drink alone or in secret. Alcohol Dependence syndrome: • Alcohol dependence refers to a cluster of symptoms. There are four min symptoms: • Craving - A strong need, or compulsion, to drinks. • Impaired control-the inability to limit one’s drinking on any given occasion. • Physical dependence-Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety, when alcohol use is stopped after a period of heavy drinking. • Tolerance-the need for increasing amounts of alcohol in order to feel its effects. The user knows that alcohol use cause significant impairment and though he/she may have a desire to cut or control its use, doesn’t or cannot give it up, resulting in heavier use of alcohol than intended and subsequent reduction of social or occupational activities. There are many factors, psychological, social, environmental, and genetic, that play dependence is not just bad behavior or a hobbit. It is a chronic and progressive disease. Alcohol Withdrawal Syndrome: This is characterized by a cluster of symptoms of varying severity, which occur on after use of repeated and usually prolonged and/or high dose alcohol. The onset and course of the withdrawal state is one of the indicators of dependence syndrome Early symptoms include tremors, vomiting, and irritability, and insomnia, signs of autonomic over activity including palpitations, sweating, raised blood pressure and anxiety. After 6-8 hour of stopping alcohol, tremulousness (also called as ‘shakes’) stars t occur which affects hand, legs and trunk. These are followed by withdrawal seizures, also known as “Rum fits”, which are seizures of generalized tonic clinic type. After 72 hours of stopping alcohol, Delirium tremens emerges. Features of delirium tremens include. • Clouding of consciousness • Fluctuating symptoms, which worsen at night • Disorientation to time, place and person • Impairment of recent memory • Illusions and perceptual distortions • Hallucinations are prominent and are usually auditory and vivid visual hallucinations • Severe agitation and restlessness. • The patient is usually fearful and shouting • Insomnia • Coarse tremors • Sweating profusely • Fever • Increased heart rate, blood pressure and dilated pupils • The period of delirium tremens usually lasts for 3 or 4 days, which is followed by deep sleep and the person awakens with little or no symptoms. • There is usually amnesia about the period of delirium tremens Alcohol withdrawal usually lasts for 1 week. There is up to 20% mortality, if is left untreated. Complications due to alcohol use Excessive alcohol use can lead to a number of complications, which can be categorized as: • Physical • Neurpsychiatnic • Social Physical (Medical) complication: Excessive consumption of alcohol can cause damage the physical health in following ways: • Direct toxic effects on certain organs, such as brain, liver, etc. • Poor diet leading to protein deficiency and Vitamin deficiency • General neglect of health • High risk behaviors • More prone to accident, particularly head injury The following includes a list of common physical (medical) complication: a. Gastrointestinal • Gastritis/ Peptic Ulcer • Oesophageal varices/ Cancer • Pancreatitis (Acute and chronic) b. Hepatobiliary • Hepatitis / Fatty liver • Cirrhosis c. Neurological • Head injury / subdural hematoma • Peripheral Neuropathy • Cerebella degeneration d. Other • Anemia, Cardiomyopathy, Myopathy, Malnutrition, Vitamin deficiencies, fetal alcohol Neuropsychiatric:- • Acute Intoxication • Alcohol dependence • Alcohol withdrawal • Wernicke’s encephalopathy • Korsakoff’s syndrome • Other psychiatric disorder: a) Delusional disorder: Delusion of Infidelity (Jealousy) — Pathological jealousy about the spouse being unfataithfuly b) Psychosis / Alcoholic hallucinousis c) Depression d) Panic disorder / other anxiety disorders e) Sexual dysfunctions f) Personality deterioration, which leads increasingly to a behavior characterized by self-centeredness, lack of consideration for other, violation of standards of conduct, not taking responsibilities and dishonest and terrible activities g) Suicidal behavior: Around 6-20% of alcohol dependent individuals commit suicide individuals commit suicide Social: • Family violence / marital • Wives of heavy drinkers are more anxious, depressed and socially isolated and they resort more to self-destructives behavior including self-poisoning • Road traffic accident / other accident • Unemployment • Emotional an conduct problems in patient’s children • Legal problems, crimes Management of Alcohol Dependence: Different phases of management include:- • Detoxification • Relapse prevention • Rehabilitation Detoxification: This phase is the initial period in which the person is detoxified from alcohol. • Benzodiazepines are the mainstay of treatment. These include Tab. Diazepam; 20-50mg/day in divided dose can be used for cases wit mild to moderate withdrawal symptoms. Benzodiazepines should not be used for more than 2 weeks to prevent dependence. Benzodiazepines should be tapered off gradually after about 72 hour of the treatment and should be stopped totally within 2 weeks. • Vitamin B1 (Thiamine) 100/mg day and other vitamins by oral or potential route need to be given • Regular Charting of pulse, blood pressure, temperature, level of consciousness, orientation and hydration needs to be done for the first 5 days • Correction of dehydration by oral or potential • Treatment of associated gastritis Detoxification is completed in about 10 to 14 days. Relapse prevention: This phase is important to prevent further episodes of the alcohol use disorder. This includes: • Correcting personal deficiencies that may lead to relapse, such as lack of assertiveness, communication skills, decision-making skills, etc. • Identifying high risk situations for replace • Avoiding high-risk situations. If avoidance is not possible, than preparing the patient to face them effectively Rehabilitation: The patient needs to be rehabilitated and socially reintegrated into the mains, stream of the society. For this, cooperation of the patient, his family member and community people are essential.