Lessons learnt from alcoholism and substance use disorders (SUDs) during the COVID-19 pandemic in India.

SUD is a widespread non-communicable disease (NCD) with biological, social, or psychological foundations which policymakers have given less attention during the COVID-19 pandemic. People with alcohol dependence went into withdrawal as a result of the lockdown and acute lack of alcohol availability, which led to black marketing and, in extreme cases, suicide. On the other hand, De-addiction services in India were not adequately equipped for the SUD pandemic, and as a result, most services could not cope with lockdown problems. To generate revenue and to get out of this Catch-22 situation, the Government opened liquor shops and sold alcohol while people purchased it as usual because of excess stress, lack of social contact, loneliness and boredom. We recommend that during COVID-19 pandemic, national, state, and local governments, as along with organisations such as Alcoholics Anonymous, develop and support networks to address the needs of patients with SUD. ©2021 Pacini Editore SRL, Pisa, Italy.

Introduction

The inability to manage the use of legal or illegal drugs or substances is referred to as substance use disorder (SUD) [1]. In India, according to the National Mental Health Survey conducted in 2015-2016, the prevalence of tobacco use disorder was 20.9 per cent, alcohol use disorder was 4.7 per cent, and drug use disorder was 0.6 per cent among the population respectively [2]. In the current scenario, COVID-19 infection and accompanying consequences are more likely in people with SUD [3, 4]. Drug abuse is included under the phrase “substance use disorder”. Any substance abuse can result in chemical changes in the brain, which can lead to addiction. The words “drug abuse” and “substance abuse” are frequently interchanged [5]. Although SUD is a widespread non-communicable disease (NCD) with biological, social, or psychological foundations which policymakers, stakeholders, and doctors have given it less attention during the COVID-19 pandemic than any other physical or mental health problem [6]. Non-consideration could be because of stigma, negative attitudes, and a lack of knowledge regarding SUD.

While the whole world has been enduring the pandemic for a few years now, many people have been going through the ongoing pandemics and post pandemic effects, although the pandemic is not yet over. In India, alcohol consumption and mental health problems are two major illnesses that have a significant impact on people, individually. When both come together, it adds to the burden of disease and creates a vicious cycle involving healthcare providers, consumers, and the patient itself. Consumption of alcohol has been identified as an important risk factor for the development of diseases, morbidity, and mortality [7]. The abuse of alcohol is a well-recognized health problem in our country and globally as well, resulting in economic loss and more hospital admissions [8]. Approximately 3.2% of deaths worldwide are caused because of alcohol each year and as per the estimates of the World Health Organization, 1/3rd of Indian males consume alcohol while the consumption of alcohol among females is increasing with the latest societal trends [9]. As per the estimates from India, Alcohol use is common both in rural and urban areas with prevalence rates ranging from 23% to 74% among males while the prevalence among females was a little lesser at 24% to 48% in a certain section and communities [9].

Alcohol acts as a small molecule, which crosses the membrane barrier and reaches different parts of the body, quickly reaching the equilibrium concentration in different cellular compartments [8]. Chronic consumption of alcohol over a period causes serious health and mental health issues involving cognition and memory problems [10]. Post alcohol dependency for any reason, it also continues to impair the decision-making capabilities. The mind keeps craving for this substance, and that is how the addiction usually start. In the long run, this hampers mental health. It can lead to various problems, such as stress, anxiety, and depression among many others.

The worrisome fact is that those facing the alcohol use disorder often have a co-occurrence of a psychiatric disorder, but they never receive regular treatment for both the conditions that address their concerns, are some worrisome findings received from the studies [11]. The correlation between alcohol and drug dependence with mental health and its associated illnesses is difficult to conclude and establish, making it even difficult to provide effective treatment options. We recommend that a combination of psychosocial as well as pharmacological approaches be integrated to treat such patients and further research to guide the best viable treatment is warranted for this cohort [12-14]. Although alcohol consumption and mental health might be interdependent on each other, there are various other factors that are necessary for observation and need to be investigated in order to arrive at a suitable correlation between the two.

To halt the spread of the COVID-19 disease, the Indian government had announced a countrywide lockdown on March 24, 2020, for three weeks at first, and then for another four and a half weeks [15]. The abrupt surge in patients with SUD (primarily alcohol) related disorders (e.g., withdrawal) was noticed because of the sudden non-availability of alcohol or opioid distribution. It resembled a pandemic’s emotional epidemic curve [16]. Around 40 people have died because of SUD-related withdrawal and suicide [17], as per the media reporting’s. People with alcohol dependence went into withdrawal as a result of the lockdown and acute lack of alcohol availability, which led to black marketing and, in extreme cases, suicide due to reported anger at not having access to alcohol [18]. Methanol intoxication has been reported in several parts of the country. Similar to Indian trends, 700 people reportedly died because of methanol intoxication in Iran [19]. Because of the lack of alcohol and bogus statements or misinformation extolling the good effects of alcohol on Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) on social media, methanol poisoning occurred because of ingesting methanol tainted alcohol [20]. Methanol poisoning is a widespread poisoning outbreak in India, affecting mostly the poor and uneducated. Methanol is a low-cost replacement that’s been added to local liquor as an adulterant. And, people believed that alcohol would protect them against the virus during the COVID-19 epidemic [21, 22].

Unfortunately, de-addiction services in India were not adequately equipped for the SUD pandemic, and as a result, most services could not cope with lockdown problems [23]. To our surprise, some jurisdictions have opted to make alcohol available to those who cannot live without it regularly, in order to treat alcohol withdrawal [24]. Though this method may be effective in the short term or in delaying the SUD epidemic, it will have a long-term impact on de-addiction efforts and treatments delivered in hospitals or community settings [25]. Most patients with SUD are unaware of the withdrawal symptoms of substances (e.g., alcohol, opioids) and have only a rudimentary understanding of the tremors [26].

Impact of the imposing COVID-19 lockdowns

The recent alterations brought about by the COVID-19 outbreak are unprecedented compared to previous crises [27]. Many countries have made valiant attempts, and lockdown being one of them is highly efficient in halting the spread of the coronavirus. During the lockdown, the international community was concerned about the rise of mental and psychosocial disorders among families and communities. A surge in substance misuse, alcoholism, and addiction has also been recorded [28]. If we dive deep to find the answer to these questions, we can easily determine many factors responsible, especially the socio-economic crisis which led to the job loss, closure of small businesses, factory units, etc. The loss was suffered by the governments, autonomous establishments, and the people. The government had to ensure supplies of essential drugs and other amenities to the people for free of cost while the people had to sit back at home to help the government prevent the spread of the Infection. People back home, are left without any job or other means of income and had to suffer from the socioeconomic crunch, eventually leading to mental health trauma [29]. In a hope that every next day the lockdown will ease out and they may return to their job, people lost all their savings on food and other activities, including paying loans/ EMIs, electricity bills etc and finally fall prey to their own deeds. Not only this, but the developing tension within homes also gave rise to the battlefield between couples and doubled the rates of domestic violence and/or divorces which is already a grave social problem in India and saw an alarming increase during the lockdown period as reported by a study [30]. To generate revenue and to get out of this Catch-22 situation, the Government opened liquor shops and sold alcohol while people purchased it as usual because of excess stress, lack of social contact, loneliness and boredom. Here the situation is tricky. Before the pandemic, the people used to work in offices, with no mental stress and there was no hue and cry situation at all. But nowadays, people work from home, and with many having no jobs, they have little money left and that too they spend on alcohol making them vulnerable for basic amenities. More social interaction is observed of such people with their family members leading to domestic violence, mental health issues, conflicts, and fights.

From the very beginning, the pandemic of COVID-19 gave multiple hard blows to every single economy in the world. It gave birth to another different pandemic-Global Unemployment. The International labour organization (ILO) recently reported unprecedented job losses [31] and according to ILO, 114 million jobs were lost globally in 2020. The global labour income saw an 8.3 per cent loss, which translates to 3.7 trillion USD [31]. Added to loss of employment opportunities, businesses of all sizes suffered huge losses owing to pandemic related closures, and many falling enterprises stated that the efforts of years/decades were ruined during the first quarter itself. While the big fishes survived the pandemic, many small businesses did not make it in through. In another report, ILO estimated 75 per cent of small-scale businesses to suffer unprecedented losses while 33 per cent are expected to lose half of their revenue in near future [32]. Conditions in India look no better and a leading business daily reported 27.11 per cent unemployment rate in May 2020, which is an unprecedented low [33]. The daily in its recent survey found that a loss of 1 crore jobs was seen in the month of May 2021 owing to the second wave of COVID-19 hitting India. The survey further reported that 97 per cent of households across the country have witnessed significant financial losses since the beginning of the pandemic in India, i.e., March 2020 [34]. A study conducted by Dun and Bradstreet, reported by another leading daily shows 82 per cent of small businesses have suffered huge losses in the pandemic during 2020 across the country. Out of those, 70 per cent of them are expected to take more than a year to return to pre-COVID status [35]. While the economy plunges lower with each new wave of COVID, the alcohol industry is among the few industries that can still generate a good amount of capital for the governments of various states and countries. Alcohol contributes to 15-25 per cent of revenues in most of the Indian states and this industry saw losses of only about 11 per cent since March 2020

Some of the major mental health issues in India amidst this pandemic are depression, insomnia, denial, anger and fear. A study by Salari et al. [36] reported that 18-80 per cent of people in the study experienced anxiety and depression as a common reaction to the pandemic. Another survey reported over 80 per cent of participants experienced anxiety and preoccupation on contracting COVID-19, 12.5 per cent had sleep issues and 34.6 per cent had distress related to social media [37]. Similarly, another study conducted during the pandemic in India revealed an increase of 67.7 per cent in suicide when compared to the year 2019 [38]. While pondering at the global scenario, some of the mental health issues faced in the pandemic were anxiety, depression, sleeping difficulties (36 per cent) or eating disorders (32 per cent), worsening of chronic disorders (12 per cent) and an increase in alcohol use and substance abuse (12 per cent) [36].

Recommendation

Based on our experience, we would advise concerned stakeholders, and physicians to raise awareness of substance withdrawal symptoms, treatment options and policy makers to register this issue for a policy on awareness and/or sensitization of general public. It looks like the only practicable and logical alternative and solution to this alarming issue. Efforts should be made to identify people with SUD quickly, assessment of the risk of early withdrawal/ intoxications, provide treatment via mobile teams or inpatient care (depending on severity), and track patients with SUD in various vulnerable or otherwise groups (e.g., suspected or diagnosed COVID-19, quarantined people).

To increase access to care for people with SUD, we advocate the introduction of tele psychiatry services, hotlines, specific cells or clinics, and a mental health surveillance system [6, 39]. Tele psychiatry may be a viable solution for people suffering from mild-to-moderate SUD withdrawal symptoms. Recently, the Board of Governors in supersession of the Medical Council of India took a significant step by issuing guidelines for telemedicine in India allowing registered medical practitioners (RMP) to consult patients/caregivers or another RMP through audio, video, text messages, email and other virtual means. This recommendation was eventually amended to allow for the prescription of clonazepam, clobazam, and phenobarbitone [40]. This strategy may be viable and safe; nevertheless, in present Indian settings, it is accompanied by scarcity of data and huge research gap. We recommend that during COVID-19 pandemic, national, state, and local governments, as along with organisations such as Alcoholics Anonymous (AA), develop and support networks to address the needs of patients with SUD and service providers in the community and hospital settings. These methods or suggestions may aid in flattening the emotional epidemic curve and improving the mental health care system’s capabilities [39].

Conclusion

The use of Alcoholism and substance use disorders (SUDs) during COVID-19 pandemic has seen sudden rise alongside mental health issues. Efforts made to identify people with SUD are very important to assess the risk of withdrawal/ intoxications quickly, provide counselling and/or treatment, depending on severity after tracking the patients with SUD. Moreover, sensitisation of policymakers on this concern is a must and foremost thing we need to do at this hour.

Acknowledgment

Authors would like to pay gratitude to all the Authors whose work has been cited in this manuscript.