New approaches for alcohol problemsRelevance for African countries Jonathan Chick Malawi, over 16 years, 2003 (WHO report) MALES FEMALES Lifetime abstainers 62% 92% Former drinkers 17% 5% Zambia 15.6% drink; of whom 44% drink heavily 40.8% of adolescents (36.7% of boys and 45.2% of girls) have drunk alcohol Acuda et al, Amer J Addictions, 2011 20. 87-99 Religious composition of populations • Zambia about 5% Muslim • Malawi 20% Muslim Alcohol use by African women Martinez et al, BMC Public Health 2011, 11:160 WHO World Health Survey 40,739 adult African women 33,841 (81%) reported lifetime abstinence. – Current use ranged from 1% in Malawi to 30% in Burkina Faso. Among current drinkers: – heavy drinking from 4% in Ghana 41% in Chad, – risky single-occasion drinking ranged from <1% in Mauritius to 58% in Chad. Problem drinking among patients attending primary healthcare units in Kampala, Uganda. Kullgren et al Afr J Psychiat. 2009 ,12:52-8. 768 consecutive patients at two centres • Do you drink alcohol? • If yes, ask the 4 CAGE questions • 2+ on CAGE - interview 9.5% DSM-IV alcohol dependence. (Only 27 out of 366 drinkers were asked about alcohol by the PHC professional. Males and high risk drinkers were more likely to be asked.) Malawi Prevalence estimates Alcohol Use disorders age 15+ – WHO, 2005) Males Females 0.66% 0.07% Harms linked to alcohol in African studies • domestic violence • risky sexual behaviors (esp. Certain drinking venues) • HIV • TB • sexual coercion • poverty • suicidal ideation and physical fighting [Swahn et al: Int J Public Health 2010: Zambia]. illegal alcohol • World Health Organisation “half of all alcohol drunk in Africa is illegal” • Uganda Waragi: (banana gin ) – Some 100 Ugandans already died from toxic waragi this year. • Botswana, laela mmago, means “goodbye mum”. • Kenya , Chang’aa = “kill me quick” Beer from grain “local beer, Lusaka beer, bwalwa, mowa, lwalwa, bucwala, bukoko, chibuku” . Malawi estimates 2005 Spirits 20% Maize or Beer Sorghum fermentation 67% 13% Alcohol Marketing, Drunkenness, and Problem Drinking among Zambian Youth: Findings from the 2004 Global School-Based Student Health Survey Swahn et al 2011 J Environ Public Health Students 11 to 16 years of age (=2257). 30% reported that they had been offered a free drink through an alcohol company representative Alcohol marketing, through providing free alcohol through a company representative, was associated with drunkenness (AOR = 1.49; 95% CI: 1.09–2.02) and problem drinking (AOR = 1.41; 95% CI: 1.06–1.87) (after controlling for demographic characteristics, risky behaviours, and alcohol education). Alcohol education was not associated with drunkenness or problem drinking. The Laws of Zambia CHAPTER 168 THE TRADITIONAL BEER ACT (d) not be supplied to anyone apparently under the age of sixteen years or to anyone already under the influence of liquor; (e) be consumed only in a place where traditional beer is sold and not be removed therefrom without the special permission of the Board Are illicit alcoholic beverages more toxic than licit? The Case of Kasippu in Sri Lanka Dr. Uditha Liyanage Postgraduate Institute of Management, Colombo, Sri Lanka ( ICAP report) Alcohol Consumption in Sri Lanka, 2006 ‘industry estimates’ Illicit Legal spirits Legal beer Total volume (million liters) 230 70 50 Alcohol content (% ABV) 30%–60% 30% 5% Total vol. (pure alcohol m.litrs) 70 18 3 Percent of the market 77% 19% 3% Alcohol & Alcoholism Vol. 43, No. 2, pp. 171–173, 2008 ILLICIT ALCOHOL CONSUMPTION AND NEUROPATHY – A PRELIMINARY STUDY IN SRI LANKA T. G. H. C. FERDINANDIS and H. J. DE SILVA Department of Physiology and Department of Medicine, Faculty of Medicine, University of Kelaniya Ethanol Methanol Arsenic/ lead Gov’t licensed arrack 36% 0.001% Not detected Illicit distillate 20.9% 0.04% Traces 0.003 ppm arsenic <0.10 ppm of lead Ferdinandis and De Silva Mean total lifetime dose ethanol per kg bodyweight - illicit alcohol drinkers 17±10.2 kg - legal spirit drinkers 15 ± 7.4 kg (P > 0.05). Alcohol & Alcoholism Vol. 43, No. 2, pp. 171–173, 2008 ILLICIT ALCOHOL CONSUMPTION AND NEUROPATHY – A PRELIMINARY STUDY IN SRI LANKA T. G. H. C. FERDINANDIS and H. J. DE SILVA Department of Physiology and Department of Medicine, Faculty of Medicine, University of Kelaniya Mild to moderate hepatomegaly: 22 of 41 (54%) illicit alcohol drinkers 11 of 17 (65%) legal spirit drinkers (P > 0.05) Peripheral nerve conduction in illicit and legal drinkers, no sig diff between those two groups. Parasympathetic response between the groups in illicit drinkers, no sig diff • High mortality from alcohol poisoning in Russia is not due to the consumption of surrogates or homemade spirits, since the latter generally meet quality standards, but to the prevalence of extremely heavy session drinking. Nuzhnyi, V. (2004). Chemical composition, toxic, and organoleptic properties of noncommercial alcohol samples. In A. Haworth & R. Simpson (Eds.), Moonshine markets: Issues in unrecorded alcohol beverage production and consumption (pp. 177–199). New York: Brunner Routledge Should African countries lower tax on alcohol to encourage switch from illicit to licit? But new drinking patterns tend to be added to, rather than to substitute for, old patterns So, ?? nation-wide use of alcohol? Is education effective? • In a health setting, YES • Brief intervention at the point of a contact with primary care is relatively inexpensive and can have a population effect Universal Prevention is Associated with Lower Prevalence of Fetal Alcohol Spectrum Disorders in Northern Cape, South Africa: A Multicentre Before– After Study Chersich et al 2012 Alcohol and Alcoholism 47, 67-74. Fetal Alcohol Spectrum Disorders highlighted in local media and health promotion talks at health facilities. Independently, two dysmorphologists and a neuropsychometrist examined 800 children at 9 and 18 months. Results Pre-intervention maternal knowledge of alcohol harms was low and FASD prevalence 8.9% (72/809). Interventions reached high coverage and knowledge levels increased substantially. FASD prevalence 5.7% post-intervention (43/751; P = 0.02); 0.73 lower odds, controlling for maternal age and ethnicity (95% confidence interval = 0.58– 0.90). No change was detected in more severe FASD forms, but in the whole population, median dysmorphology scores reduced from 4 [inter-quartile range (IQR) = 2–7] to 3 (IQR = 1–6; P = 0.002). The 6 most effective ways of reducing the burden of alcohol harm in a society after Babor et al 2010. and WHO Minimum legal purchase age Government monopoly of retail sales Restrictions on hours or days of sale, density of outlets Alcohol taxes Road safety sobriety check-points, lowered blood alcohol concentration (BAC) limits, administrative licence suspension, graduated licensing for novice drivers Brief interventions for hazardous drinkers Treatment: (1) DETECTION • Detection, detection! Train staff! • Information from family • Do not ignore a raised MCV or abnormal serum liver enzyme result! • Do not diagnose acute anxiety if it might be alcohol withdrawal symptoms! Identification of individuals at risk from a dangerous withdrawal reaction • History • Recent consumption of over 15 units/day • Continuous daily drinking rather than heavy sessions for a couple of days Treating withdrawal symptoms Medication : to prevent seizures and DTs : help over first 4-5 days while person, motivated to change their drinking, tries to abstain Diazepam 40-60mg in 1st 24 hours, reducing to zero over 5 days. Treatment (2) Helping the patient who is trying to abstain Alcohol addiction damages the soul • Dishonesty • Selfishness • Egocentricity/arrogance • Preoccupation • Isolation • Life narrows • Blames others/ Does not take responsibility All to PROTECT the supply of alcohol Loss, despair, suicide “We are on the case and in control” Alcohol addicts keep believing they have the problem under control ..............so they refuse help Spirituality: Whatever is that? ‘It is not necessary to hold formal religious beliefs, or engage in religious practices, or belong to an established faith tradition, to experience the spiritual dimension’ Royal College of Psychiatrists Spirituality is identified with experiencing a deep-seated sense of meaning and purpose in life, together with a sense of belonging. It is about acceptance, integration and wholeness. Spirituality = ‘Higher Power’ • “linking the deeply personal with the universal”, • inclusive and unifying. • leads to the recognition that to harm another is to harm oneself, and equally that helping others is to help oneself. It applies to everyone, including those who do not believe in God or a ‘higher being’. Alcoholics Anonymous? AA meetings Blantyre, Lilongwe , Lusaka, Nairobi Randomised controlled trials of facilitating AA affiliation Project MATCH Research group Addiction 1997;92:1671-98 Randomised Controlled trial of intensive referral to 12 step self help groups: Timko and DeBenedetti, Drug Alc Depend 2007; 90:270-9 Effectiveness of Making Alcoholics Anonymous Easier: a group format 12-step facilitation approach Kaskutas LAJ Subst Abuse Treat. 2009 37(3):228-39.. Mentorship Tracy et al. Alcohol and Alcoholism, 2012 Well accepted by patients At 6 months 10% advantage in abstinence You can’t learn to navigate in a ship that’s sinking Medications (1) Deterrent: Antabuse (only effective if supervised) Longest follow-up study 7 years – 50% maintain complete abstinence Alcohol works through neurotransmitters •GABA & Glutamate – primary neurotransmitters •Amines [eg serotonin] & Peptides [eg endorphins] •– modulatory neurotransmitters Medications (2) • Acamprosate: expensive, 3 times/day, for helps severely dependent daily drinkers (about 1 in 7) to abstain completely. • Naltrexone: opiate antagonist, now generic, licensed in many but not all countries. Helps reduce frequency of heavy sessions (about 1 in 6) How alcohol works1. Glutamate activates the brain excitation + Glutamate GLUTAMATE cell POSTSYNAPTIC NEURON NEURON PRESYNAPTIC NEURON learning & memory + in excess anxiety & seizures 2. GABA calms the brain excitation + Glutamate GLUTAMATE cell NEURON + GLUTAMATE inhibition GABA NEURON Sedation, calming, muscle relaxation, unsteadiness etc 3. Alcohol – the ‘double whammy’ 3. Alcohol - theAlcohol double whammy blocks glutamate excitation Glutamate GLUTAMAT cell E NEURON + + GABA inhibition Alcohol enhances GABA Baclofen (1) • stimulates GABA-B receptors (i.e. an agonist) • (Benzodiazepines e.g.diazepam s are GABA-A agonists) • Mild anti-anxiety action. Aids sleep. • Available world wide • Cheap $0.01 per tablet! Baclofen (2) • • • • • 85% excreted in kidney 15% liver metabolism Give at least three times per day max 100mg/day Some reports of much higher doses, but unwanted effects: excess sedation; transient psychosis or hypomania • Tolerance up to a certain dose; not abused Republic of Malawi National Alcohol Policy Ministry of Health Malawi Alcohol Strategy Final Draft 2011 Limit alcohol advertising by content of messages and volume per a given period through product placement on radio, TV and internet through e-mails and mobile phones particularly targeting young ones; Limit sponsorships for cultural or sports events as well as promotional competitions of alcohol products; Set deterrence systems for infringements on marketing restrictions; All alcoholic beverages must carry health warning labels; Malawi Alcohol Strategy Final draft 2011 • Provide the framework for addressing alcohol availability, distribution, sales, marketing and consumption; • ……………. • Malawi Government, through Parliament, shall identify with the consequences of alcohol-related costs to development, therefore, commit revenues from alcohol taxes to addressing them. • ............................ • “Increase taxes by percentage volume of alcohol” Malawi Alcohol Strategy Final Draft 2011 • • • • • • • Provide producer-license for alcohol products; Provide for a reasonable number of retail outlets per locality; Restrict wholesale and retailing systems by licensing; Enforce minimum purchase and consumption age (cutoff age 18) Limit by time and hours for opening (3pm) and closing (9pm) of outlets; Restrict areas by density and location of outlets; Classify retail outlets as bottlestores, bars, and shops for license and time administration; Zikomo!