Sri Lankans, especially males, drink a fair amount of alcohol. Surveys show that more than half of Sri Lankan males over 15 are alcohol users and, a majority of them have had alcohol use related problems at some point in their lives. Over the years, deaths from liver diseases – an indirect measurement of alcohol consumption- have steadily increased.

Other surveys show that among the urban poor in Sri Lanka, in one third of households, one third of their income is spent on alcohol.

Alcohol also figures significantly in road traffic accidents. It is estimated that 40 per cent of those involved in such accidents had consumed excessive amounts of alcohol. Add to this, domestic and workplace disputes and disharmony resulting from alcohol use and you would see that alcohol is a significant, preventable, cause of human misery.

Yet, the use of alcohol within certain limits is socially sanctioned. Weddings and other social functions in Sri Lanka are considered incomplete without alcohol. The quality and cost of the liquor served is considered a good measure of the wealth and social standing of the host.

Certain types of alcohol such as red wine are also considered to have health benefits. This leads us to several important questions. Is it possible to drink alcohol safely? Are people who become addicted to alcohol different to those who do not? Is addiction to alcohol a disease and if so can it be treated with medication?

Is it possible to drink alcohol safely?

The Royal College of Physicians’ guidelines for ‘safe drinking’ published many years ago recommended that males should drink no more than 21 units of alcohol per week and females no more than 14. There should be 2-3 alcohol free days per week they said, adding that there is an increased risk of liver disease for those who drink daily or near daily, compared with those who drink periodically or intermittently.
A unit of alcohol is 8 grams of pure alcohol.

Hence, a bottle of beer would contain 2.5 units of alcohol and a bottle of spirits, 27 units. These limits have been criticised as being too high. In Sri Lanka it has been found that even people who drink below these limits have developed a condition called fatty liver, an early sign of liver damage, which could lead to cirrhosis, a stage of irreversible severe liver damage which in turn could cause liver failure and death.

So what is the safe limit? Perhaps if we were to cut these recommended limits in half and state that males should drink not more than 10 units per week, and women not more than seven, provided this amount is distributed over the week, it would probably be safe for health in most people.

However, if you are driving there is really no safe limit for alcohol. Even below so called legal limits of blood alcohol, driving reflexes are significantly impaired. One study found that several hours after consuming alcohol, when the blood alcohol levels were zero, drivers still had impairment of their reflexes. So if you intend to drive, the safest option is not to drink at all.

Pregnant women should avoid alcohol altogether. Drinking during pregnancy can lead to defects in the baby such as low birth weight, behavioural and thinking problems, defects of the heart and other organs and abnormal facial features. If severe, it is called the foetal alcohol syndrome.

There can be other consequences of alcohol addiction. In the American classification of mental illnesses, alcohol abuse or harmful use of alcohol is defined as one or more of the following in the past 12 months:

• use resulting in failure to fulfil major role obligations,
• use in situations that are physically hazardous,
• use leading to legal problems,
• continued use despite causing (or exacerbation of) interpersonal problems.

Hence the amount of alcohol used really does not matter. If you have used alcohol in the past year in such a manner as to cause any of the harmful effects listed above then you have a problem and should seek help.
Harmful use of alcohol is not the same as addiction or dependence.

The American classification would define dependence as use manifested by three or more of the following in the last 12 months:

• tolerance,
• withdrawal,
• use of larger amounts than intended,
• persistent desire or failures to reduce or control use,
• lot of time spent on alcohol use activities,
• social activities given up because of alcohol use and continued use despite causing (exacerbation of) physical or psychological problems.

Tolerance is having to use increasing amounts of alcohol to get the same effect and withdrawal is the classic hangover effects of tremor and sweating and anxiety. A person who is dependent needs expert help to overcome his problem.

Are people who become addicted to alcohol different from those who don’t get addicted even after years of social drinking? It is known that people transit in stages over the years, from recreational use to harmful use and, finally to dependence or addiction. Most people do not progress to dependence but use alcohol recreationally without harm or indulge in harmful use at times.

Researchers have studied the genetic make-up of people who have become addicted and found that the genetic make-up does matter significantly. In a study on tobacco smoking it was found that in people who experiment with smoking, the environmental contribution was 60% and the genetic contribution 40%. In those who were nicotine dependent, the genetic contribution was 75% and the environmental contribution only 25%.

In another study done among adolescents using alcohol it was found that adolescents with a certain genetic make-up were more liable to become addicted to alcohol than those who did not have high risk genes. However, it was also found in this study that, even in the adolescents having the high risk genes, if parental control was strict, they were less liable to become addicted. So the lesson is perhaps, do be strict with your adolescents and it will protect them from addictive behaviours. The environment can make a difference even if the genes are bad.

Is alcohol addiction a disease? Models and theories as to the cause of alcohol addiction have changed over the years. In the 19th century it was thought that alcohol abuse was due to moral weakness and the solution was to put such people in prison or place them in institutions where they were given moral education. At the end of the 19th century this changed to a chemical model where alcohol was thought of as a dangerous chemical and the solution was to eradicate this dangerous drug from society. This led to methods such as prohibition in the US which in turn led to bigger problems of organised gangs cashing in on the shortage of alcohol. At the beginning of the 20th century people started to think of addiction as a personality disorder which could be treated by psychoanalysis. However the results were discouraging.

After the Second World War an American psychiatrist called Jellinek put forward the disease model of alcoholism. In the 70’s it was thought that alcohol addiction was a result of learned behaviour which could be unlearned through behavioural treatment. Around this time the social model also became prominent and people started to think that addictive behaviour was normal behaviour in abnormal circumstances. Just change the circumstances and the abnormal behaviour would also change.

Later people put together the biological, psychological and social models and came up with an integrated model known as the biopsychosocial model. This is the current model, though in the last decade or so, more attention has been paid to the biological aspects of the model.

It is now known that there is an important circuit in the brain called the reward circuit, and stimulation of this circuit by addictive substances such as alcohol leads to the secretion of dopamine which is inherently pleasurable to the brain.

Alcohol dependence or addiction is the most stigmatised disease in the world, not only among the general public, but unfortunately even among members of the medical profession. It is quite likely that a person admitted for an alcohol problem to hospital is likely to receive less medical care than say for a heart problem. Coupled with this stigmatisation is a sense of helplessness or therapeutic nihilism and it is known that even in countries where drugs that can help with alcohol addiction have been available for many years doctors do not prescribe them.

So if you think you, or a member of your family, has an alcohol problem please do seek help. And members of the medical profession please make use of the medicines that are available. It can make a world of a difference not only to the patient but to the patient’s family and even to society.

Treatment

Are there medicines that can be given to treat addiction to alcohol? The answer is, yes there are three such medicines that have been found to be useful in the treatment of alcohol addiction. They may not be 100% effective, but they are of significant benefit in helping people overcome their addiction problem.
4Disulfiram, a drug discovered more than 50 years ago works by blocking an enzyme which is critical for the breakdown of alcohol in the liver, leading to the accumulation of a toxic substance called aldehyde. This causes unpleasant even dangerous symptoms such as nausea, vomiting, flushing and increased blood pressure. Once a person swallows a tablet of disulfiram it will remain in the body for up to two days and, if alcohol in any form is consumed, it will cause the unpleasant symptoms described above. This medicine should only be used with the full consent of the patient preferably under supervision. It should never be added to food without the knowledge of the patient.

4Acamprosate works by reducing the craving for alcohol and works best in people who have given up alcohol completely and want help in remaining abstinent.

4Naltrexone which was launched in Sri Lanka only a few weeks ago works directly on the reward circuits of the brain blocking the secretion of dopamine when alcohol is consumed. The advantage of this medicine is that it can be given in persons who are continuing to drink and reduces the amount of drinking in persons who have not yet decided to be abstinent.

A nation of drinkers

Department of Excise figures show that in 2011 the amount of spirits produced was 54 million litres of spirits and 88 million litres of beer. The amount of illicit alcohol produced probably exceeds that of spirits. The figures are probably more for this year, and considering that women in Sri Lanka hardly drink, the people who do drink appear to consume a large volume of alcohol.

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