It was March 28, Day 4 of the nationwide lockdown imposed in response to the novel coronavirus pandemic. Kerala government’s 14405 Vimukthi de-addiction helpline saw a sudden spike in calls: from eight on March 24, they shot up to 201. One call was from the wife of a 42-year-old daily wage worker in Ernakulam. The man, who had an eight-year history of alcohol dependence, was huddled beneath his bed with his daughter who, he was convinced, was going to be attacked. There was no such danger, but he was hallucinating.
Around the same time, a 45-year-old man was brought in by his family to the Centre for Addiction Medicine at Bengaluru’s National Institute of Mental Health and Neurosciences (NIMHANS). The man, also with a history of alcohol use, had suffered three seizures, was dehydrated and comatose. He was one of 89 patients who came to the centre within a week of the lockdown, said Lekhansh Shukla, an assistant professor there. “This was a big jump; we ordinarily see two or three such cases a day,” he said.
In Chennai, a week after the lockdown, Karthik (name changed on request) was brought to the Institute of Mental Health by his parents. He hadn’t slept in five days and was hallucinating. “I believed a group of people had entered my house and were beating me up,” the 31-year-old, who works as a driver with an app-based service, told us. “I couldn’t tell the difference between reality and hallucination.”
Tip of the iceberg
Each of these men was experiencing severe withdrawal symptoms, triggered by the sudden unavailability of alcohol after the
lockdown, when all shops except groceries and pharmacies were shut down. Alcohol withdrawal symptoms can range from shivering, dehydration and sleeplessness to more acute conditions such as delirium, hallucinations, fever, vomiting and seizures.
Within a week of the lockdown, reports of deaths and suicides related to alcohol withdrawal began to rise. In Tamil Nadu, for instance, 10 deaths have been reported in this time, many of them caused because addicts consumed dangerous substances in lieu
er, and methyl alcohol. The last few decades have seen alcohol abuse grow into a major public health problem. As far back as 2009, a report in The Lancet found that more than half of all alcohol drinkers in India fall into the ‘hazardous drinking’ category. A 2018 report by WHO noted that about 2.6 lakh deaths in India each year can be directly or indirectly traced to excessive alcohol consumption.
The majority of alcohol drinkers across India are men, but the percentage in some States is higher than the national average of 29.2%, according to the National Family Health Survey 2015-16. In Tamil Nadu, it is 46.7%; in Kerala 37% and in Andhra Pradesh 34.9%.
What worries Dr. Shukla is the scant awareness about treatment, and the curtailed access to medical centres at this time when public transport is closed. “The people we are seeing with alcohol withdrawal is just the tip of the iceberg — we can assume that most people have not made it to a hospital and have suffered. Studies tell us that the mortality rate for people with severe withdrawals is over 15%.”
Healthcare professionals are also worried about the impact on families: there has been a withdrawal-related spike in incidents of domestic violence, said Maya Varadarajan, managing trustee of TTK Hospital for Addiction, a Central government-designated Regional Resource and Training Centre. The hospital has been closed since the lockdown, but its counsellors are working from home, checking up on patients.
Serious distress
The treatment protocol for people suffering from alcohol withdrawal syndrome is to admit them, do blood investigations and brain imaging, check for fractures that could have occurred during falls, check for malnutrition and dehydration, and give intravenous benzodiazepines and high doses of vitamins.
On March 30, the Kerala government issued an order that said that since a section of people were undergoing serious distress, some even attempting suicide, due to alcohol unavailability, a process should be initiated to make a limited amount of alcohol
available to them. But doctors petitioned the Kerala High Court against the order. “The order to issue passes to obtain alcohol was a peculiar one and not scientific. Medicines and complete abstinence from alcohol are used to treat alcohol-withdrawal symptoms,” said G.S. Vijayakrishnan, general secretary, Kerala Government Medical Officers Association. On April 2, a division bench of the Kerala High Court stayed the government order for three weeks.
Today, as part of Vimukthi, Kerala’s anti-narcotics campaign, 14 de-addiction centres operate at district or taluk hospitals across the State. Each centre has 10 beds now, and the process of expanding facilities by another 10-20 beds is under way in each district, according to D. Rajeev, Additional Excise Commissioner and CEO of the Vimukthi Mission.
Harm minimisation
Tamil Nadu’s District Mental Health Programme, meanwhile, foreseeing a rise in alcohol withdrawal cases, has chalked out a set of guidelines for medical officers and district psychiatrists. The State-run Institute of Mental Health in Chennai is functioning round-the-clock, with a counselling helpline, in addition to the State health helpline. Diazepam, a drug used to treat alcohol withdrawal, is available at all Primary Health Centres, said IMH director P. Poorna Chandrika.
If alcohol dependent people today find themselves in such difficult straits, it’s symptomatic of the state’s contradictory approach to alcohol, which is both puritanical and pragmatic, said Soumitra Pathare, Director of the Centre for Mental Health Law and Policy in Pune. “Alcohol is seen as morally repugnant — but it is also a huge revenue generator for the state. What we need during lockdown is a harm minimisation approach, where people are given access to de-addiction treatment, but where people are also allowed to decide when they want to undergo treatment, because unplanned withdrawal can be life threatening,” said Dr. Pathare.
With inputs from Divya Gandhi.
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