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 (𝑁=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!