Alcohol problem in eastern Nepal: our Observations Dr. Dhana Ratna Shakya MD-Psych, MBBS Associate Professor Department of Psychiatry, BPKIHS, NEPAL Email:
[email protected] URL: http://np.linkedin.com/pub/dhana-ratna-shakya/1b/265/764, http://www.researchgate.net/profile/Dhana_Shakya_Dr2/ (August 27-28, 2013. PAN-Synapse, Kathmandu, Nepal)
BPKIHS, Nepal
Alcohol problem in eastern Nepal Introduction Problem introduction (Global, Nepal- National) Alcohol problem address in eastern Nepal/ BPKIHS Alcohol problem in eastern Nepal- community prevalence • Clinical/ hospital epidemiology • Problem data among Medical students • Etiological factors • • • •
• • • • • • • • • • •
Alcohol content Co-morbidity observations Alcohol- a great threat for health Gender comparison KAP about ARD Help seeking Assessment/ Screening tool Management of ARD Other observations Areas being addressed Some future directions
Alcohol problem in eastern Nepal: Introduction • Common in eastern Nepal, reported remarkably high • Various aspects of this problem: the topic of search, study, survey and research • Aim: review articles, research projects presented in scientific forum or conferences, thesis articles submitted and other research works related • Medical journals (including HR), abstract books, internet search and personal communication with various departments of BPKIHS • Over arching objective: Point out some important needs and areas for future research studies
Alcohol problem: Global • • • • •
a part of human life immemorially alcohol use- a global phenomenon Various forms of alcohol are used One of 2, tobacco topping the list of licit substances about 2 billion people use alcohol globally [United Nations Office on Drugs and Crime (UNODC) report, 2011]
• worldwide total consumption 6.13 liters pure alcohol/ person of 15 years and older age, 2005 • World’s 3rd largest risk factor for disease burden (after childhood underweight, unsafe sex): about 4.5% DALY in 2009 (WHO)
NEPAL: Lumbini- Birth place of Buddha
Nepal & Eastern Nepal • a landlocked country in between China & India • total area: 147,181 sq. kms • rich cultural heritage and bio-diversity: multi-ethnic, multicultural, multi-linguistic, multi-religious environments and geographical diversity Eastern Region of Nepal : • an important in terms of economic and other resources • occupies about 1/5th- country’s area and 1/4th- population • Multiethnic and multi-lingual population, with about half from ‘Matawali’ category
National scenario of Alcohol problem • limited systematic community studies in Nepal about alcohol use and related problems • alcohol ab/use and problems prevalent and No. 1 problem substance in Nepal Shrestha DM, Shrestha BK. Tobacco & Alcohol use in Nepal. Paper presented at WHO Regional Consultation on Tobacco & Alcohol, Srilanka. 1997. Shrestha NM. Prevention of Alcohol and Drug Problem in Nepal. J Nepal Med Assoc. 1993;220-232.
National scenario- II • Alcohol use : permissible; also encouraged in ‘Matawali’ tradition. Traditional barrier among ‘Tagadhari’ is getting weaker in current Nepal. Shakya DR, Shyangwa PM, Sen B. A study of socio-demographic profile, psychiatric comorbidities and help seeking behavior in ADS attending BPKIHS, Nepal. MD thesis. 2005.
• Civil society : indifferent; except sporadic campaign against alcohol use, mainly by female activists and at one time by Maoist cadres
National scenario- III • impose additional levy & ban electronic advertisement • Dff= k= ;]= hf“r : current movement in valley with palpable impact of short term reduction of RTAs • lack solid plan & program to address problem; policy & strategies from Government to limit production, distribution & consumption • Industry products of alcoholic beverages make a huge presence besides home products (some places are largely known for!) • few N/GOs in substance field, more so for alcohol
Alcohol- problem situation and research in eastern Nepal • Alcohol ab/use is huge; evident in the alcohol literature from in eastern Nepal • BPKIHS, a centre of research & medical education in this part • some commendable research work in this common but usually neglected topic from this region • review the available literature about various aspects of alcohol use and related problems in eastern Nepal
Shakya DR. Alcohol ab/use in eastern Nepal: a review of studies. Health Renaissance. 2013; 11(1):74-82.
Alcohol- problem prevalence in eastern Nepal community • Comprehensive data with different sectors- lacking • a community-based survey among 2344 randomized house hold samples of Dharan: prevalence of current alcohol use problem was 25.8% with heavy drinking (i.e. 2 CAGE) in 19.5% (male 28.4% and female 11.67%) • higher among those with the status of increasing age, lower levels of education, widowers, divorcees and those from ‘Matawali’ community Jhingan HP, Shyangwa PM, Sharma A, Prasad KMR, Khandelwal SK. Prevalence of alcohol dependence in a town in Nepal as assessed by CAGE questionnaire. Addiction, 1998, 339-43.
Problem in eastern Nepal community -II • 2340 cluster samples of women of age> 15 yrs in Dharan: prevalence of alcohol consumption in 17% • higher rates among women from hilly ethnic groups, divorcees and smokers. • A striking proportion, 9% of pregnant women reported to drink alcoholic beverages Niraula SR, Shyangwa PM, Jha N, Paudel RK, Pokharel PK. Alcohol use among women in a town of Eastern Nepal. JNMA. 2004; 43:244-9.
Problem in eastern Nepal community -III • Among 911 subjects from 3 districts, one each from Mountain (Sankhuwasawa 300), Hill (Dhankutta 302) and Terai (Sunsari 309) of eastern Nepal, 4.06% had MINI (Alcohol abuse/ dependence) diagnosis: 3rd after depression and anxiety Shyangwa PM, Shakya DR, Adhikari BR, Pandey AK, Sapkota N et.al. Community based survey on Psychiatric morbidity in eastern Nepal. Report presented to NIC.
• Current psychiatric diagnoses in 200 Dharan DM community subjects: alcohol dependence/abuse was found in 5.5%; after depression (10%) & anxiety (8.5%) Basnet M, Shakya DR, Deo BK, Sharma SK. Prevalence of Psychiatric comorbidity in Diabetic patients in Dharan. MD thesis. 2012..
eastern Nepal community -III • current use of alcohol 11.1% with random sampling method among 1889 school students of Dharan Deo BK, Shyangwa PM, Kumar R, Jha N. Survey on KAP of alcohol & other substance use/abuse among high school students in Dharan. (2003).
• 5% health camp attendees- alcohol/ substance use disorders Shakya DR. Functional status and Psychiatric morbidity among help seekers in a specialist camp in a city of eastern Nepal. Abstract book. Annual Scientific Program, BPKIHS; 2011. Pp. 156-7.
• 45.7% FSWs- history of having sex (past/ present) after usealcohol; 70% of them involved in last encounter Sagtani RA, Bhattarai S, Adhikari BR et al. Alcohol use, HIV risk behavior & experience of sexually transmitted infections among FSWs of Nepal. Clinical Epidemiology & Global Health. 2013; 1-6.
Clinical/ hospital epidemiology • Alcohol abuse in 8% & dependence in 32.3% of the hospital based samples using AUDIT and SCID Pradhan B, Chappius F, Karki P, Rijal S, Baral DD, Hadengue A, Gache A. A Survey of Alcohol use disorders in a Nepalese population. Abstract book. Annual Scientific Program, BPKIHS, 2011. Pp. 63.
• 8% of referred psychiatry OPD cases Shakya DR, Pandey AK, Shyangwa PM, Shakya R. Psychiatric morbidity profiles of referred Psychiatry OPD patients in a general hospital. Indian Medical Journal. 2009; 103(12):407-11.
• 3% of Nobel medical college OPD cases (substance) Koirala NR, Yadav R, Das AK, Poudel J, Bhagat SK. Socio-demographic & Diagnostic profile of pts attending Psychiatric OPD of Nobel MC, Biratngr. JNMC. 2012.1(2):45-49.
• 17% of psychiatry in-patients (BPKIHS. In-patient record-2068)
Clinical/ hospital epidemiology-II Alcohol/substance problem the most common diagnosis: • 24% of psychiatric consultation liaison Shakya R, Shakya DR, Lamichhane N, Shyangwa PM, Sapkota N, et al. Study on Consultation Liaison Psychiatric Service in General Hospital Psychiatric Unit in Eastern Nepal. Abstract book. SPFC-2, Nepal, Nov, 2006. P 76.
• 29.5% of the cases seen in psychiatric emergencies Shakya DR, Shyangwa PM, Shakya R. Psychiatric emergencies in a Tertiary care Hospital. JNMA. 2008; 47(169):28-33.
• Majority of cirrhosis (86%) in BPKIHS alcoholic cirrhosis Maskey R, Karki P, Ahmed SV, Manandhar DN. Clinical profile of patients with cirrhosis in a tertiary care hospital, Dharan, Nepal. NMCJ.2011;13(2):115-8.
Clinical/ hospital epidemiology-III • 18% of surgical and medical in/out patients of BPKIHS using the AUDIT. Sharma A, Shah B, Joshi M, Khandelwal SK. Alcohol Problem in a General Hospital in Eastern Nepal. Nepalese J Psychiatry. 1999; (1):41-5.
• 32% of people living with HIV/AIDS seeking help from HIV clinic of BPKIHS had CAGE score of ≥ 2 Shakya DR, Lama S, Thapa LJ, Shyangwa PM. Psychiatric disorders in adult .people living with HIV/ AIDS attending a tertiary care hospital. Scientific forum of BPKIHS, 2011.
• 14% of elderly psychiatric out-patients Shakya DR. Psychiatric morbidities of elderly psychiatry out-patients in a tertiary-care hospital. J Coll Med Scienc. 2011; 7(4):1-8.
Clinical/ hospital epidemiology-III • 20% with AUD among foreign job holders presented in BPKIHS psychiatric service Shyangwa PM, Lamichhane N, Shakya R, Shakya DR. Psychiatry morbidity in foreign job holders. JGMC. 2009; 2(2):45-52.
• Among mentally ill female spouses of Nepalese abroad workers seeking help from BPKIHS Psychiatric service, 40% currently drink & 4% alcohol use disorder Shakya DR. Psychiatric Morbidity Profiles of female Spouses of Nepalese abroad workers. Abstract book. 10th World congress of WAPR. Bangalore, India November, 2010. Pp. 158-9.
Clinical/ hospital epidemiology-IV • 16.9% drivers were found to have consumed alcohol 2-3 hrs prior to RTA Jha N, Agrawal CS. Epidemiological Study of Road Traffic Accident Cases: A Study from Eastern Nepal. Regional Health Forum. 2004,8(1):15-22
• 12% of seizure disorder out-patients of psychiatry department currently use alcohol Shakya DR. Psychiatric symptoms and disorders in seizure cases referred to psychiatric out-patient service. J Neuroscience & Behavioural Health. 2013; 5(1):13-19. Available online at http://www.academicjournals.org/JNBH
Alcohol ab/use in medical people • 63.5% of medical students/ junior doctors of BPKIHS ‘ever used’ substance, 56.5% used ‘last yr’ & 42.5% in ‘last mth’ • Alcohol most preferred (90.9%) • 1/3rd females had ever used Shyangwa PM, Joshi D, Lal R. Alcohol and other substance use/abuse among junior doctors and medical students in a teaching institute. JNMA 2007;46(167):126-9.
• 67.29% ever used substances, mainly alcohol and nicotine. Alcohol abuse/ dependence- 8.22% (SCID-I) Shakya DR, Shyangwa PM, Shakya R, Agrawal CS. Mental and behavioral problems in medical students of BPKIHS. Asian J Psychiatry. 2011; 4(1):S61.
Causes/circumstance of alcohol ab/use • most problem-drinkers first drink in the pretext of social custom (as food), peer pressure, stress and easy availability • Females- various stressors predisposing, precipitating or perpetuating the disorder (27.5% male vs. 40% female) Shakya DR (2008). Circumstances of 1st drink among Problem drinkers seeking help from Psychiatric service of a Teaching institute in EN.
• Psychiatric co-morbidity, f/h of ADS and pre-morbid personality disorders- important factors for relapse of ADS Shyangwa PM, Sharma R, Mallick L, Pande AK, et al. Clinical profile & Factors contributing to complicated withdrawal of ADS patient in the 1st yr after starting of De-addiction ward at BPKIHS. CME-KU, Dhulikhel. Oct, 2010. Sharma R, Pande AK, Shyangwa PM. Short term outcome and Factors associated with Relapse of Alcohol dependence: a prospective study. Unpublished- MD thesis. 2011.
Causes/ Circumstances
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• various factors- higher daily alcohol intake, physical comorbidity and higher serum AST and Bilirubin significantly associated with the development of delirium tremens Thapa KB, Sen B, Shyangwa PM. Risk factors associated with DT & its treatment with BZPs. Unpublished-MD thesis. 2002.
Alcohol content • Local samples of brewed alcohols analyzed for concentration in Lab of Geneva University Hospitals: Raksi 25%, Jand or Chhyang 12% and Tongba 5.5% Pradhan B, Chappuis F, Baral D, Karki P, Rijal S, Hadengue A, Gache P. The AUDIT: validation of a Nepali version for the detection of alcohol use disorders and hazardous drinking in medical settings. Substance Abuse Treatment, Prevention, and Policy 2012, 7:42
Co-morbidity observations • 3/4th used other substance too, main nicotine, opioid & cannabis • Majority presented to hospital when had complications: physical, mental & social, occupational, and many others Shakya DR, Shyangwa PM, Sen B. A study of socio-demographic profile, psychiatric comorbidities and help seeking behavior in ADS attending BPKIHS, Nepal. MD thesis. 2005.
• 80% had other psychiatric co-morbidities (62% psychiatric & 51% personality). Main co-morbid psychiatric disorders- anxiety, mood affective and psychotic disorders. Personality- dissocial, narcissistic and anxious Shakya DR, Shyangwa PM, Sen B. Psychiatric co-morbidity in Cases admitted for Alcohol Dependence. Delhi J of Psychiatry.09; 12(2):252-7
Co-morbidity II • Subsequent and other studies also show remarkable comorbidities in varying rates here Gautam R, Shyangwa PM, Shakya DR, Smith S, Pradhan B. Female patients with alcohol related problems: Clinical profiles, Co-morbidity and their attitude. Unpublished- MD thesis. 2010. Sharma R, Pande AK, Shyangwa PM. Short term outcome and Factors associated with Relapse of Alcohol dependence: a prospective study. Unpublished- MD thesis. 2011.
• 85% admitted ADS cases had physical co-morbidities, mainly: diseases of GIT and hepato-biliary system; followed by CNS and CVS Shakya DR, Shyangwa PM, Sen B. Physical Diseases in Cases Admitted for Alcohol Dependence. HR. 2008; 5(1):27-31.
Alcohol- a great threat for health • hazardous alcohol use was significantly higher in panic than in depressive disorder and normal subject groups Singh PM, Sen B, Das SK, Shyangwa PM. Panic Disorder: A study of clinical features and association with events and alcohol use in a tertiary hospital in eastern Nepal. Unpublished- MD thesis. 2003.
• alcohol habit has a significant adverse effect on adherence to treatment regimen and blood sugar control in type 2 DM Thapa B, Pokharel P, Jha N, Paudel I, et al. Alcohol consuming habits & its effects on adherence and blood glucose level in type-2 diabetes mellitus in a town population in eastern region of Nepal. HR,11; 9(2): 95-101.
• An association of alcohol use in about 30% of DSH attempters; 5.5% used for 1st time prior, 9% harmful use and 5.5% ADS Shakya DR. Alcohol use in Suicide attempters: A study of the association. Abstract book. Annual Scientific Program, BPKIHS; Aug, 2011. Pp. 158.
Gender comparison • Nepalese males start drinking at younger ages than females • first drink was more associated with stressors in females • Perceived stressor was significantly more among females influencing the course (54.66% m vs. 80.00% f, P- 0.001) • Common stressors- males: strained inter-personal relationship, substance use by near and dear, own’s disease, death of some near and dear and recent festivals; females: strained relationship, death of near and dear, other life events, some near and dear away from home etc. • Onset- gradual & course/ pattern- continuous: both genders Shakya DR, Shyangwa PM, Sen B. Gender comparison of clinical-course of alcohol related disorders among psychiatric help seekers from a tertiarycare-hospital in eastern Nepal. 64th ANCIPS Kochi, Jan, 2012. Pp. 73.
KAP about ARD • Attitude towards alcohol use among females- positive but knowledge regarding health hazard- inadequate Gautam R, Shyangwa PM, Shakya DR, Smith S, Pradhan B. Female patients with alcohol related problems: Clinical profiles, Co-morbidity and their attitude. Unpublished- MD thesis. 2010.
• Dharan’s people more concerned about social & medical consequences of alcohol; urged to take problem seriously & increase preventive measures: awareness & collaboration Bridel C, Tschopp V, Waber LR, Schibler M. Alcohol, Drugs & illegal substance uses in Dharan: Qualitative study. Unpublished thesis.2003.
• Main cause of abuse (73.63%) bad companion & positive attitude towards abusers Deo BK, Shyangwa PM, Kumar R, Jha N. Survey on KAP of alcohol & other substance use/abuse among high school students in Dharan. (2003).
Help seeking in alcohol problem • People seek help only when develop physical (liver or gastrointestinal problem) or psychiatric problems Sharma S. Alcoholic liver disease at BPKIHS, at 3 mth observational study 01.
• main reason for treatment delay is the lack of realization that drinking/ consequences as a problem • 96% resort to some home remedies, e.g. rituals, visiting temples, traditional herbal preparations, giving soft drinks or other substances in place of more concentrated alcoholic beverages, Shakya DR, Shyangwa PM, Sen B. Help seeking behavior in patients with alcohol dependence in a tertiary care hospital in eastern Nepal. J Psychiatrists’ association of Nepal (JPAN). 2011; 1(1):15-9.
Assessment/ Screening tool • AUDIT (Nepali version)- a reliable and valid screening tool (in reference to SCID-I) to identify AUDs in Nepalese population. • AUDIT- good capacity to discriminate dependent patients (with AUDIT ≥11 for both the gender) and hazardous drinkers (with AUDIT ≥5 for males and ≥4 for females). • For alcohol dependence/ abuse the cut off values ≥ 9 for both males and females Pradhan B, Chappuis F, Baral D, Karki P, Rijal S, Hadengue A, Gache P. The AUDIT: validation of a Nepali version for the detection of alcohol use disorders and hazardous drinking in medical settings. Substance Abuse Treatment, Prevention, and Policy 2012, 7:42
Management of alcohol problem • Gamma GT and MCV levels ↑ in ALD. ↑ Gamma GT (e. 25 IU/I), MCV (e. 100 fl/I) and AST/ALT ratio (>1) show a strong association with ALD. The degree of elevation of AST was found higher than that of ALT in ALD Baral N, Pokharel S, Lamsal M, Yadav BN, Sah SP. Utility of GGT & MCV in ALD. Southeast Asia J Trop Med Public Health. 2005; 36(4):1007-10.
• mild to moderate disproportionate elevation of AST than ALT (De Ritis Ratio > 2:1), supported by reversal Albumin/Globulin ratio facilitates the diagnosis of ALD Majhi S, Baral N, Lamsal M, Mehta KD. De Ritis ratio as diagnostic marker of alcoholic liver disease. Nepal Med Coll J. 2006 Mar;8(1):40-2.
Management-II • Both Chlordiazepoxide and Lorazepam equally effective in treatment of delirium tremens (DT) Thapa KB, Sen B, Shyangwa PM. Risk factors associated with DT & its treatment with BZPs. Unpublished-MD thesis. 2002.
• Review of secondary data- role of local services of Deaddiction unit of BPKIHS, KYC (Kirat Yakthung Chumlung) & DYC (Dharan Youth Club) in this area Niraula SR, Chhetri DB, Singh GK, Nagesh S, Shyangwa PM. Role of Rehabilitation centers in reducing drug abusers in Dharan. KUMJ 2006; 4(4): 448-54.
Other Observations • premarital sexual relationship in 66.7%, extra-marital 58.8%, multiple partners 51.3%, contact with CSW 21.7% and that with known HIV/HBV positive 9.6% among abusers from rehabilitation centers. About 30.0% drive drunken, 61.7% of intravenous drug users (IVDU) exchanged needles and 41.5% reused and high proportion was involved in anti-social behaviors Rai M, Quyyoom Z. Risk taking Behaviors among drug abusers of Dharan & factors preventing them from seeking treatment.Unpublished thesis.2001.
• ‘Empty nest syndrome’- an obstacle for alcohol abstinence for a middle aged lady Shakya DR. Empty nest syndrome- An obstacle for Alcohol abstinence: A Case Report. JNHRC. 2009; 7(2):135-7.
Other Observations • Anxiety- psychiatric co-morbidity as obstacle for abstinence Shakya DR. An Obstacle for Alcohol abstinence: A case report. J Institute of Medicine. 2009; 31(2): 34-6.
• ‘Substance ab/use in eastern Nepal’- Current situation, Responses and Future strategies Shyangwa PM, Shakya DR. Substance Use in Eastern Nepal: Current Situation, Response & Future Strategy. Souvenir: SAARC Psychiatric Federation International Conference-2. Nepal, Nov, 2006. P. 38-9.
Medications available • Detoxification- tab. / inj. Lorazepam (TRAPEX), tab./ inj. Diazepam, tab. Chrodiazepoxide, inj. Midazolam, tab. Carbamazepine (tab. ZEPTOL), • Deterrent- Disulfiram • Naltrexone • Acamprosate • Topiramate • Anti-craving- Fluoxetine (cap. PRODEP)
Non-drug strategies • Psycho-education • Motivation enhancement strategies (motivation stage assessment, insight into harm of use and benefit of abstinence, risk/ trigger/ cue identification, rehearsal, abstinence strategies) • Address the relapse factors • Individual, Couple, Family, Interpersonal intervention • Social strategies- AA • Regular follow ups • Rehabilitation (Centers, society)
Client counseling series
Web-pages: Mental health Nepal Papers/ magazine etc.
TAKE HOME MESSAGE
• Collaboration and exchange of ideas, experiences and observations • Similar situation in various parts of the country • Thanks for excellent forum for sharing the information
