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

by - September 16, 2014

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. 

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  1. Only pray alcoholists understand this. They no doubt suffer, but equally their 'innocent' families suffer as well. I recently lost a cousin to this. And I can see the pain of his wife and teenage son.

    1. Thats the sad part... the goal should have been to educate and wean those who are spiralling into destruction. Instead, they have decided to just abruptly shut everything and suddenly, the whole state is facing impending financial ruin... it woulf have been funny if we were not part of the state itself and forced to watch this absurdity!

  2. Prohibition has been experimented in Haryana, Andhra Pradesh, etc. and it has never worked except to increase bootlegging. Gujarat is the shining example of prohibition yet every single desi and imported brand of daru is available for those who can afford. Those who can not rely on the cheap adulterated desi versions.

    1. The scary part is that they've still not done anything to stop access to liquor. Prohibition in year one means bars shut down. All the outlets still sell it... so now people will get it for cheaper and booze at home. Great logic...

  3. I agree banning alcohol will not resolve the problem.We need a lot more reforms than that. It surprises me that govt is taking a decision without even considering a long term effect of the action.

    1. Its a really bad way to reach the "desired effect"... reeks of a poor thought process.

  4. Sigh, the problem of excesses. Anything done in moderation is better, in my opinion. A blanket ban on alcohol can also be phased out, right?

    1. Exactly... there is a right way to do this, if it is necessary. This is just causing further burden to the rest of the state financially to prove a point...

  5. Replies
    1. That is common sense... ironically lacking in the state with 100% literacy

  6. The world is talking about legalizing prostitution and drugs. Our country wants to go the Saudi way. I say, just improve the legal system in our country and everything, everything will improve.

    1. Improve the legal system??? of India? Aliens would come to Earth, colonize, take over all our resources and leave before that day comes! :)
      We are definitely on the way back to the medieval ages... we just aren't ready to say it out loud.

  7. Alcohol prohibition has worked in Gujarat only because it is so close to Daman and Diu..

    I have friends who are from Daman and they told me you get beer in normal general stores ! When people go on vacation, they bring the alcohol with them to Gujarat, there is about a 50% chance of police checking your car at the state boundary. And whatever the police finds, they actually resell it again in Gujarat.

    I honestly dont get the whole alcohol prohibition thing, why do we even need prohibition? Why do we need the legal drinking age limit to be extended ?

    If you are in Delhi and you are 24 years old,its legal for you to vote, to get married and have children...BUT you cannot order a drink ! It sounds so stupid I am almost ashamed of my country

    1. yes, I am well aware of the 'prohibition' in Gujarat... have heard first hand accounts from docs over there myself.
      This started off because a bunch of politicians started playing the moral card against the Chief minister. Affronted, he decided to go all in (to use poker terms) and so without any clue on how make up the deficit he is causing, just signed the papers and took moral high ground...
      We are in for a lot of stupidity in the coming days, I fear... everyone needs to prove their way is better.

  8. like we discussed before,now thanks to NOT banning the 5 star hotel bars, daily wagers can drink at 500 rupees instead of 50 rupees..

    1. exactly... all these meetings to make up this great decision and not one of these 'exalted' leaders thought about that. Makes you wonder what the heck goes on in these meetings...

  9. As you rightly said Doc, it's all about making people aware of the danger of binge drinking rather than indulging in rhetoric. It doesn't help the cause at all. But, the post was informative on the danger of excessive alcohol consumption.
    Btw, check my review of Railonama and let me know!

    1. As someone mentioned above, everything in excess is bad... definitely that applies to alcoholism. But then, that applies to religious beliefs and medicines too. Is the answer to ban all religions and hospitals? These people have not shown the basic sense in all this.

      And thanks for the review, man ... :)

  10. You have not included Ahmedabad in the cities you have polled, this is a conspiracy against Modi :-P

    On a more serious note, I am not in support of the ban. But I believe the alcoholism is on rise in India and is affecting the entire society in one way or the other. Specially in the lower strata of society where the money for children's nutrition, health and education is blown on the local liquor store, might see some semblance because of this ban.

    1. I totally agree. But that is the problem... instead of identifying the leaks in their system, they have just chosen a blanket ban. That has never worked favorably anywhere.. and note the loopholes: people will still be able to buy booze (at a lesser rate than they were buying presently) from the liquor shops for the next 10 years. Just that now they are expected to drink at home. How is this going to help the system in any way?

  11. I don't understand why the government gets a say in whether or not a person should drink.. Yes, too much is not good and irresponsible...But banning it is crazy in this day and age and that too in the manner that you have just enunciated..

    1. That is my point... there has never been any widespread campaign to educate the public against alcohol beyond the lame "statutory warning" next to ads... banning is just ill thought of and in the end grossly counter productive to the state

  12. and what about smoking?? how come they have not put a ban on something which is potentially more harmful not just to the person but to those around him?? the government decided that smoking is no serious issue i guess


Let me know what you think.