DR. AJAY RISAL
There is a famous Japanese proverb, “First a man takes a drink, then the drink takes a drink, then the drink takes the man.” I think many instances have revealed this alarming picture, “…then the drink takes the man…”
Earlier, during the third year of my medical studentship, the days when we would be made to examine the patients ‘with distended abdomen, yellowish sclera and flapping tremors’ lying on the beds of medical wards, the personal history of those patients with full details of their alcohol use would alarm us much. Ultimately, those patients would turn out to be the cases of Alcoholic Cirrhosis or Hepatitis who would land up in the ICU either with Variceal bleeding or Hepatic Encephalopathy. Most of them would die of Aspiration Pneumonia or blood loss, while some of them who survived would promise to stop drinking, but sooner or later, would relapse with the same fate. Hence, I always thought
“alcohol” was a health toxin for all the middle class or working class people who drink uncontrollably, in a binge, careless enough to fully ruin their health. Though some researchers have pointed out the cardiac benefit of mild to moderate drinking, on risk-benefit analysis, I always regard alcohol as gravely injurious to health.
During residency in psychiatry, I got to study deeper in this area as my thesis topic was related to the medical morbidities associated with alcohol. Comparison among the Alcohol Dependent patients in our medical college and a government district hospital showed medical morbidities, relapse rate and case fatality almost similar in both the treatment centers. So, we concluded that people of any class or region will have similar effects of alcohol. Sooner or later, they would be dependent, fall in the course of frequent relapses and end up with long lasting medical morbidities.
Working in a university medical college as a psychiatrist for the last two years, I get ample opportunities to hear from these patients referred from medical wards and witness their multitude of morbidities. After psychological therapies and counseling, when we try to explain the medical model, they often say, “Now, I will stop it forever,” but after a few weeks, they relapse. Such a course and treatment trajectory moves on and on.
“Alcohol and alcoholism” is not a new area to dig. Since ancient times, alcohol has remained in the society, as a cultural prescription or a social proscription. In the Western countries, it is regarded to be of nutritive value while in our part of the world, it has anthropological significance. Some societies restrict its use as a “taboo” while in some, alcohol remains as a buffer “to celebrate a joy” or “to share the sorrow”.
Hence, alcohol use is born in a family and grows in the society. Psychiatrist and geneticist Cloninger (1944) has rightly classified alcoholism to be “male-limited” or “milieu limited”. Genetics has a deep underpinning in Alcohol Dependence as shown in some researches on “Sons of Alcoholics”. Social atmosphere ranging from peer pressure to the cultural set up, workplace environment and legal provision all are the determining factors. “Easy availability” and “unrestricted transportation” all promote cosmopolitan effect of alcohol. “Novelty seeking” and “reward dependence” have been considered to be the key temperamental issues uncovering the masked psycho- behavioral aspects of alcohol dependence. Depression, Mania, Anxiety and many personality disorders (Impulsive, Antisocial etc) are the psychiatric illnesses found to be comorbid with alcohol use and abuse.
We consider Alcohol Dependence “a disease” rather than merely labeling it as a bad habit, maladaptive behavior or punishable crime. Its relapsing course as explained earlier shows how difficult it is to treat or cure this illness. It cannot be treated just by restricting them indoors or asking them to join some religious activities. Punishing them, ignoring or ridiculing them would rather be counter-productive.
Rehabilitating them taking the help of former alcohol dependent patients (currently abstinent) in a form of group therapy (Alcoholic Anonymous, AA) would be a better option, provided all of them have been detoxified and started on some maintenance treatment. Co-morbid psychiatric and medical illnesses need to be treated in a multidimensional care set up consulting physicians, hepatologists, neurologists and any other consultants considering the individual need of the patient.
There is a misconception among the patient party. They consider only the hard drinks available in the market as a drink (i.e, raksi in Nepali), while homemade local drinks (i.e, jand, chhyang) and beer widespread in every street of the country are not considered harmful. So, educating the public that “all these drinks are alcoholic beverages (in variable percentages) and harmful in excess” is a must.
The attempt here is for awakening the concerned public, clinicians, social workers and authority figures that alcohol dependence is a big public and social health problem that needs to be tackled in a holistic manner because it is certain that…”…then the drink takes the man…is family…and the society…”
Dr. Risal is Psychiatrist at Dhulikhel Hospital