Alcohol Withdrawal: Just another thing Kerala is not prepared for post-prohibition

Today, I am going to be focusing on a topic which I predict is going to discussed across the country (and especially in my home state) quite extensively in the days to come, once the new 'alcohol prohibition' law is enforced in God's Own Country.

While this can also be seen as a medical article, the main aim of this post is to share it with my fellow Keralites so that they can spot the symptoms at the earliest, both as individuals and as doctors.

Let me start off with the key point - Alcohol Withdrawal Syndrome (AWS) is not a joke. People can die from it. No, really!

It commonly affects those who have been binge drinkers or drink regularly for consistent periods of time (usually months or years) and are then forced to stop it or significantly reduce the quantity abruptly. Remember how some of your imbibing friends may show off that they do not get drunk even after 5 - 6 pegs? Ya, that's not as cool a thing as they imagine and you may want to let them know that.

AWS can be extremely detrimental to the body as early as two hours after the last drink. Symptom progression involves:

• Anxiety
• Nervousness
• Irritability
• Sweating
• Shaky hands
• Severe headache
• Nausea and vomiting
• Insomnia

Unfortunately, all those points I mentioned are the good stuff. After that, things get worse.

Hallucinations start to develop (visual/tactile/auditory). Again, this ain't the worst of it. It may then progress to seizures and a condition called delirium tremens.

Delirium tremens is the most severe manifestation of alcohol withdrawal and can occur as early as 72 hours after the last drink. It occurs in 5- 10% of people suffering from AWSRegarding the features, to the doctors, I would say, think of it as autonomic hyperactivity. To the lay person, let's just say that every key system of your body goes into overdrive. Thus you have:

• Increased heart rate
• Hyperventilation
• Nervousness, sweating & irritability
• Confusion of time, place and surroundings
• Hallucinations (they see insects, bugs, rats or feel that insects are crawling within their skin)
• Fever
• Raised blood pressure
• Anxiety
• Paranoia

Death rate:

With treatment in a hospital, up to 15 % may still die.

Without treatment in a hospital, the death rate goes up to 35 %.

For the doctors interested in the physiology behind this:

Ethanol (alcohol) triggers cessation of endogenous GABA production --> downregulation of GABA receptors + upregulation of excitatory neurotransmitters --> individual needs more alcohol to get drunk. 

Stop drinking now and there are now not enough GABA receptors for GABA to land on, leaving them flying around freely while norepinephrine, dopamine, epinephrine and serotonin are already having fun thanks to increased excitatory neurotansmitters --> conditions similar to an 'adrenergic storm'.

Treatment involves hospitalization and initiation of benzodiazepine therapy in addition to focusing on natural products to alleviate other non-specific symptoms.

What you can do: 

If a chronic alcoholic is suddenly made to cease drinking (as is the wonderful game plan presently in play), do not take their initial complaints of nervousness/headaches lightly. The usual answer is to smile and joke about how they are missing alcohol and that the feelings will go away soon. They may wish to take a supplement, like CBD, to help them manage things like pain, as well as feelings of stress and anxiety, and you could perhaps help by showing them a resource like this guide on how to take hemp oil orally to ensure they are taking it properly in order to get the best absorption and effect possible. Whatever they may come to you for, listen to them, look for signs of progression of illness and do not hesitate to take them to a hospital if the symptoms start to get worse. 

My personal view on the ban:

I am not a big fan of the present prohibition policy that my state has come up with. It seems like a half-baked idea set up by individuals in power to assert a moral superiority over the others. I would have been less critical had they shown some sense of a long term vision but the fact is the present policy is riddled with so many holes, it could make for awesome lacy lingerie.

Image courtesy: MusafirNamah

• If the aim is prohibition, why is it that government outlets are being allowed to sell alcohol at all? Why phase it out over ten years? 
• If bars are closed and the government is still selling liquor to the public, essentially you are allowing them to get it for a cheaper rate (as opposed to bar prices) and take it home to drink? This is your master plan?
• Why should alcohol be available in five star hotels? Are you suggesting that only the rich have the body physiology to drink responsibly? To an outsider, it would suspiciously appear as though you carved the pie out so that you get to keep drinking while telling the general public it is bad to drink.
• What about the bootlegging mafia for illicit liquor? How do you curb that? You can't - that is a fact. Which means we should await the next generation of budding Dawoods and Rajans now, thanks to you. (Hey, if you can use extreme side-effects while discussing alcohol, so can I! ) 
• What awareness programs have you run to curb the frequency of alcohol consumption? I'm curious to know since I have not seen any in the media. 
• You talk of a loss of 7500 crores in the first year from this alcohol prohibition alone. Yet there is no back up plan chalked out to make up the deficit. In fact, the state just borrowed Rs 100 crores last week from RBI because they did not have funds to pay government employees during the Onam holiday. You don't have the means for 100 crores and you are going to make up 7500 crores in 365 days? Pray, do tell me how. 
• Oh yes, I forgot... by your second most successful industry - "tourism" of God's Own Country. Only initial surveys already show that nearly sixty percent of the public would choose not to travel to Kerala thanks to the new rules. So that industry goes down the drain too. 
• Have you set up proper facilities and centers across the state to deal with cases of alcohol withdrawal syndrome which is what is already being discussed by physicians as an impending epidemic in our state in coming days. In fact, they have already read up and prepared for identifying cases and initiating treatment. But what have you done?

Nobody is condoning alcohol and the abuse factor. Too much of anything is always harmful and fatal... look no further than your religious beliefs and the people who corrupt it with their extremist views for that. But this is not something you can justify with a one-line sentence. There is a huge difference between having a single glass at the end of a long day and getting hammered and disturbing the peace. Equating one end of the spectrum with the other is absurdity. There has been more damage and loss of wealth & life in Kerala from the hartals and violence caused by your political parties - perhaps we have to consider banning the whole lot of you instead. The right way to go about it was to conduct awareness programmes (and no, you did not do enough so don't try to argue on that). That is Community Medicine 101. 

For me, the whole thing promises to be a monumental fiasco which is going to cripple and bankrupt our state in 365 days. Where the state will make up the money lost from alcohol and tourism is beyond any of us, but then we are not allowed to discuss it lest we be seen as supporters of the booze, right? The makers of this law have effectively asked us to jump off a plane and promised us that they will stitch a parachute and send it to us before we hit the ground. 

Well, good luck with that.