Alcohol use disorder research in India: An update

Abstract

Background:

Despite alcohol use being a risk factor for numerous health-related conditions and alcohol use disorder (AUD) recognized as a disease, there was limited research in India until 2010. This narrative review aims to evaluate AUD-related research in India from 2010 to July 2023.

Methods:

A PubMed search used key terms for AUD in India after 2010. Indian and international journals with regional significance that publish alcohol-related research were searched by each author individually. These were then collated, and duplicates were removed. In addition, we also conducted a gray literature search on focused areas related to AUD.

Results:

The alcohol-related research in India after 2010 focused on diverse areas associated with alcohol use. Some areas of research have received more attention than others. Two major epidemiological surveys conducted in the past decade reveal that around 5% have a problematic alcohol use pattern. Factors associated with alcohol use, like genetic, neurobiological, psychological, and sociocultural, were studied. The studies focused on the clinical profile of AUD, including their correlates, such as craving, withdrawal, alcohol-related harm, and comorbid psychiatric and medical illnesses. During this period, minimal research was conducted to understand AUD’s laboratory biomarkers, course, and prognosis. While there was a focus on generating evidence for different psychological interventions for alcohol dependence in management-related research, pharmacological studies centered on anticraving agents like baclofen. Research on noninvasive brain stimulation, such as rTMS, has shown preliminary usefulness in treating alcohol dependence. Very little research has been conducted regarding alcohol policy.

Conclusion:

In the past decade, Indian research on alcohol has focused on diverse areas. Epidemiological and psychological management-related research received maximum attention. Considering the magnitude of the alcohol-related burden, it is essential to prioritize research to other less studied areas like pharmacological management of alcohol dependence and alcohol policy.

INTRODUCTION

Alcohol use has captivated the attention of numerous experts in the realm of health, especially concerning mental health. This domain carries significant ramifications for public health, giving rise to a considerable body of research. A comprehensive analysis conducted in 2010 encompassed the entirety of substance use research in India.[1] However, it mainly emphasized the Indian Journal of Psychiatry (IJP) and reviewed other literature selectively. Consequently, within this review, our focus shifts toward exploring research conducted in India about alcohol use and its associated disorders from 2010 onward, with a focus on national and international mental health journals.

METHODOLOGY

For this review, a comprehensive and systematic search was conducted on PubMed keywords “Alcohol use disorder” OR “Alcohol Dependence” AND “India” with a filter from 2010 employed in the search, targeting titles and abstracts of articles [See Supplementary Material]. Furthermore, independently, we have searched specific journals: the Indian Journal of Psychiatry, the Indian Journal of Psychological Medicine, the Industrial Psychiatry Journal, and the Indian Journal of Social Psychiatry. Additionally, we have reviewed the Asian Journal of Psychiatry, an international publication that frequently features Indian research. The search process encompassed using advanced search engines within each journal above.

Following this initial phase, a meticulous assessment of abstracts was carried out to identify and select pertinent research work, namely, original research articles, systematic reviews, and case series, all possessing significant implications for the Indian populace. Materials such as letters to editors, narrative reviews, and abstracts from annual conference presentations were purposefully excluded from consideration. Furthermore, a study of references cited within the selected articles was undertaken to ensure the inclusion of all relevant content. We have summarized the research findings in various sections and sub-sections.

EPIDEMIOLOGICAL RESEARCH

National surveys

The National Mental Health Survey (NMHS) covered 12 Indian states, conducting 39,532 tablet-assisted personal interviews. Using a multistage, stratified, random cluster sampling approach, eligible subjects aged 18 years and above were selected from households. The study utilized Mini-International Neuropsychiatric Interviews (M.I.N.I.). The prevalence of alcohol use disorder (AUD) was 4.7%, with a notable male predominance (9.1% vs 0.5%). Among those seeking care and treatment, the median expenditure was the highest for AUD, amounting to 2250 INR.[2]

The Magnitude of Substance Use in India, 2019 (National Drug Use Survey 2019, NDUS) was the first-ever comprehensive attempt to document the extent and pattern of substance use at the level of states of India. The WHO ASSIST screening questionnaire was used to interview 200,111 households in 36 states and Union Territories (UTs). Alcohol emerged as the most prevalent psychoactive substance, with 14.6% of the population aged 10–75 using it, including 5.2% with problematic usage and 2.7% dependent. Men had notably higher usage rates at 27.3% compared to women at 1.6% and children aged 10–17 at 1.3%. Country liquor and spirits were the most consumed types.[3]

NMHS and NDUS highlighted a significant “treatment gap” for substance use disorders. NMHS reported that this gap is exceptionally high for AUD (86%) compared to other drug use disorders (73%). The NDUS survey also reflected this pattern, revealing that only one in 37 individuals with AUD and one in 20 with drug use disorders had received any treatment.[2,3]

The National Family Health Survey 2019–21 (NFHS-5), funded by India’s Ministry of Health and Family Welfare (MoHFW), covered every state and UT as of March 2017. The survey highlights that only 1% of women and 19% of men reported alcohol consumption. Among female drinkers, 17% consume almost daily, with 37% drinking weekly. In contrast, 15% of male drinkers consume almost daily, 43% drink weekly, and 42% drink less frequently than weekly. Notably, alcohol use is more prevalent among uneducated men, scheduled tribes, and those aged 35–49. The states with the highest alcohol consumption rates among women are Arunachal Pradesh (24%) and Sikkim (16%), while for men, the states are Arunachal Pradesh (53%) and Telangana (43%). Despite an overall decrease in alcohol use compared to previous surveys, there has been an uptick in the proportion of men reporting frequent alcohol consumption.[4]

From nationwide “Niyantrita Madhumeha Bharata” diabetes trial in 2017, a door-to-door cross-sectional survey with 30,354 participants highlighted an estimated 8.7% alcohol abuse prevalence (15.8% male, 2.4% female). Notably, Arunachal Pradesh had the highest abuse rates for alcohol, while Tripura had the lowest.[5]

Another study analyzed community-based prevalence data from various sources from 2000 to 2020.[6] Twenty-one studies from different states in India, encompassing 73,997 community respondents, were included. The overall prevalence of AUDs was estimated at 12.5%. The pooled prevalence based on the Alcohol Use Disorders Identification Test (AUDIT) showed 8.6% hazardous and harmful alcohol use and 2.3% dependent alcohol use.

Regional epidemiological studies

Apart from national surveys, some vital regional studies have been conducted, listed in Table 1.

Table 1.

Epidemiological studies on alcohol use (nationwide survey, regional surveys, and concerning vulnerable populations)

Important findings from the three major nationwide surveys
Survey						Prevalence
National Mental Health Survey 2016						4.7% AUD
National Survey on Extent and Pattern of Substance Use 2019						14.6% use alcohol 5.2% problem users 2.7% dependent users
National Family Health Survey-5 (NFHS-5) 2021						1% of women and 19% of men use alcohol
Regional epidemiological studies of alcohol use
Author and Year of publication		Region		Methodology		Important Findings
Manimunda et al., 2017[7]		Andaman and Nicobar Islands.		18,018 individuals aged ≥14 were surveyed using AUDIT.		Alcohol use prevalence was 35% in males and 6% in females aged 14+. Among alcohol users, two-fifths were hazardous drinkers, and 23% were alcohol dependent. Dominant beverages were homebrews like toddy.
Kumar S et al., 2013[8]		Rural Tamil Nadu		A cross-sectional study among 946 subjects aged ten years and above using the AUDIT scale		Alcohol use prevalence is 9.4%. Males had a higher prevalence (16.8%) than females (1.3%), with initiation at the mean age of 25. Among alcohol users, 29% and 34% were possibly hazardous drinkers and dependent, respectively.
Sujiv et al., 2015[9]		Puducherry’s primary care setting		Cross-sectional study on 256 subjects using the AUDIT scale		39.8% were current alcohol users, with 27.4% with AUD among current users.
Kim et al., 2013[10]		Urban Vellore slum		Cross-sectional screening of 2811 men		Alcohol use – 46.1%. Among users, 31.4% were hazardous drinkers. Factors associated with alcohol use included manual labor jobs, common mental disorders, and smoking.
Ghosh et al., 2012[11]		Kolkata, West Bengal		Cross-sectional survey		Current users were 65.8%, with harmful use and dependence being 8% and 14% respectively among current users. About 62% of dependent users showed clinical signs of chronic use.
Rathod SD et al., 2015[12]		Sehore District, Madhya Pradesh		A population-based cross-sectional study (n=3220)		23.8% of men and 0.6% of women reported alcohol consumption in the past year. Among drinkers, 33.2% exhibited hazardous drinking, 3.3% harmful drinking, and 5.5% dependent drinking.
Sukumaran A et al., 2020[13]		Trivandrum district, Kerala		A cross-sectional study through interviews using a questionnaire (n=1545)		An overall prevalence of current alcohol use at 9.5%, with significantly higher rates among males (18.3%) compared to females (0.4%).
Alcohol use epidemiological studies on vulnerable population
Author and Year of publication		Methodology				Important Findings
Suhadev et al., 2011[14]		A cross-sectional study of TB patients at Chennai’s corporation health centers (n=490)				29% consuming alcohol and 15% scored >8 in AUDIT. Age (>35), lower education, lower income, marital status (separated/divorced), and Category 2 treatment were significantly linked to alcohol use among TB patients.
Veerakumar et al., 2015[15]		A cross-sectional study (n=235) of urban PHCs registered under RNTCP in Pondicherry				AUD in 54% at diagnosis and 26.4% during treatment. Though among initial drinkers, 80% adjusted alcohol use postdiagnosis, 1/3rd of patients continued alcohol use during treatment.
Thummar & Rupani, 2020[16]		A cross-sectional study assessed hazardous alcohol use (using AUDIT scale) and its predictors among TB patients (n=200) in Bhavnagar, Gujarat				Hazardous alcohol use prevalence was 20%. Regular smokeless tobacco use, father’s alcohol use history, exposure to spurious liquor brewing areas, and belonging to scheduled caste/scheduled tribe emerged as significant predictors
Thomas et al., 2019[17]		A multicenter prospective cohort study involving 455 newly diagnosed adult pulmonary TB patients				10% scored ≥8 on the AUDIT scale, indicating alcohol misuse. The study indicated that simultaneous alcohol misuse and smoking heighten the risk of negative outcomes during TB treatment
Quraishi et al., 2022.[18]		A study measured the prevalence of alcohol use and the predictive value of biomarkers.				They reported that 22% of patients reported daily alcohol intake, 63% reported weekly intake, and 16% reported monthly intake
Varshney et al., 2016[19]		A prospective study in Delhi assessing ASSIST-linked BI in individuals receiving OST				26% had ASSIST scores in the harmful hazardous category.
Sartaj et al., 2021[20]		The study investigating mental illness and substance use among Hijra individuals through interviews with 50 self-identified Hijras accessing HIV-prevention services in New Delhi.				The study showed that a high rate (38%) of lifetime mental illness, mainly tied to alcohol abuse (26%), linked to the quality-of-life factors and experiences of discrimination and disempowerment.
Bhattacharjee et al., 2012[21]		A cross-sectional study of 200 individuals who survived suicide attempts in rural India examined the role of alcohol.				17% had a history of alcohol use before their attempt, with 15% meeting the criteria for AUD. These individuals also tended to make more lethal suicide attempts.
Kattimani et al., 2016)[22]		A record-based study involving 147 suicide attempters				21% of attempts involved alcohol intoxication. Those attempting suicide under alcohol influence were typically older, male, married, and employed and had fewer years of education. Marital status and living conditions were predictive factors for attempts under alcohol intoxication.
Krishna M and Vanamali[23]		A cross-sectional study to investigate the prevalence of alcoholism among emergency department patients				62 (43.05%) were identified as alcoholics by treating doctors in the emergency department. Additional 11 patients (7.63%) were identified as alcoholics from records, with 2 (1.38%) meeting criteria for severe alcoholism.

Epidemiological studies concerning special population

1. Adolescents and young adults

   A cross-sectional survey in Assam employed a predesigned questionnaire on 1285 school-going students. Among them, 36% tasted homemade alcoholic drinks (HADs), while 12.3% tried commercially available alcoholic drinks (CADs). The first exposure to CAD was at 7 years and HAD at 4 years. Parental tobacco/alcohol habits influenced children; fathers’ habits linked to male CAD use.[24] In Kerala, a cross-sectional survey among 5784 college students revealed varying lifetime alcohol prevalence: nursing students 10.6%, “other” stream (law/fisheries) 41.7%. Medicine and nursing students had lower hazardous usage. Male gender and tobacco use increased risk, while Muslims had lower risk.[25] Another community-based cross-sectional study with a stratified multistage random sample design investigated substance use patterns among Chandigarh college students (N = 256). Of the 135 substance users, alcohol was the most prevalent (53.5%).[26]

2. Women

   A study reported noteworthy alcohol-related issues in rural Telangana women. ICD-10 criteria and the CAGE Questionnaire were employed. Findings disclosed 4.1% dependence, 1% problematic drinking, 4.1% physical complications, 1% psychiatric comorbidity, and 4.4% pregnancy-related drinking.[27]

3. Medical fraternity

   In a cross-sectional web-based survey with the primary objectives of assessing the prevalence and predictors of suicide ideation among medical students (N = 506), 17% reported having consumed alcohol, and 2.3% consumed alcohol once or more a month.[28] Conducted in eight Indian medical colleges, a multicenter study reported ever alcohol use to be 16.6% and 31.5% among UG and PG students, respectively, with higher usage among males.[29] A systematic review and meta-analysis analyzed alcohol use prevalence among medical students, covering 31 studies from 2000 to 2022, including those published in non-PubMed indexed journals. The overall prevalence of ever alcohol use in this population was 27.1% (95% CI: 23.0% to 31.1%, n = 11,823), with notably higher odds among males.[30]

Epidemiological studies on different occupational groups

A cross-sectional study among 371 male construction workers in Puducherry reported alcohol use in 48%. ASSIST scores showed a moderate risk for almost half of alcohol users (49.8%). Current alcohol use is tied to work duration and health problems.[31] Another community-based cross-sectional study in Puducherry focused on fishermen in a selected hamlet. Harmful alcohol use was found to be as high as 76.8%. Probable dependence was found in 12.4% of alcohol users.[32]

Epidemiological studies on other vulnerable populations

Alcohol use is linked to tuberculosis (TB). A few studies that aimed to explore alcohol use among TB patients have been listed in Table 1. Hazardous alcohol use in opioid-dependent patients receiving opioid substitution therapy (OST) is frequent and typically adversely affects their treatment outcomes. Two studies assessed prevalence in this population [see Table 1 subsection]. A few studies also addressed prevalence in other vulnerable populations like Hijras and suicide attempters in whom alcohol use is relatively common. See Table 1, last subsection, for more details.

FACTORS ASSOCIATED WITH ALCOHOL USE

Biological factors

Genetics

In India, genetic studies focused on evaluating the role of NPY (Neuropeptide-Y), GABA receptor, 5HTTLPR (serotonin), DRD2 (dopamine), and EPHX1 (epoxide hydroxylase) genes among patients with AUD during this period.[33,34,35,36,37] A study reported that COMT polymorphism (Met158 variant) is associated with increased AUD risk; GABA polymorphism was a protective genotype.[38]

Bhaskar et al. studied populations from Kota and Badaga in South India (both having different ethnic histories).[39,40] The study investigated the role of VNTR polymorphisms in DAT1 in patients with AUD. The A9 allele of the DAT gene was significantly associated with AUD in Bagada participants (and not in the Kota participants), thus suggesting their involvement in vulnerability to AUD.

Studies among the Meitei community, Manipur, found participants carrying the A1 allele of the Ankyrin repeat and kinase domain containing 1 (ANKK1) TaqIA polymorphism were more vulnerable to the development of AUD.[41] There is no difference in the extent of MTHFR C677T gene polymorphism.[42] Quraishi et al.[43] examined the association between Ankyrin repeats and kinase domain containing 1 (ANKK1) gene polymorphism and alcohol use-related variables. AUD patients with an A1 genotype were 2.5 times more likely to report higher alcohol consumption. The study emphasized the need for higher attention to A1 carriers by the service providers. In another study, AUD patients with COMT Met allele reported higher alcohol consumption.[44] Similarly, a study aimed to assess the association between N-methyl-D-aspartate receptor 2B subunit (GRIN2B) polymorphism and alcohol withdrawal-related parameters among 220 AUD cases and 183 ethnically matched randomly selected controls.[45] AUD patients with T allele at this locus had a significantly lower age of onset for alcohol withdrawal symptoms. The role of cholinergic genes (CHRM2) in patients with a risk of delirium tremens was studied.[46]

A study in central India evaluated the genotypic distribution and the allelic frequencies of genes involved in alcohol metabolism.[47] The study reported the prevalence for ALDH2, GSTM1, and GSST1 polymorphism was 3.38%, thus being an at-risk population for alcohol-related liver disorders.

Limited literature has also been accrued on AUD’s genetics and comorbid liver complications. A recent study aimed to evaluate the ALDH2 locus in AUD patients with and without liver cirrhosis in South India.[48] The study reported that the ALDH2 methylation was significantly lower in patients with AUD comorbid with cirrhosis than in those without cirrhosis. Global DNA methylation (long interspersed nucleotide element 1) levels were lower in subjects with comorbid cirrhosis. Thus, DNA methylation may have a role in liver cirrhosis and may be explored as a biomarker. Epigenetic studies also revealed the persistence of DNA methylation during the follow-up periods, irrespective of the status of alcohol use.[49] Another recent study from North India included 128 AUD patients with ALD, 184 AUD patients without ALD, and 152 controls without AUD.[50] As per the study findings, enhanced CD14 expression increases vulnerability to developing ALD among AUD patients with TT genotype.

Neuroimaging

Structural, metabolic, and functional imaging studies have been conducted to understand the neurobiological substrates of AUD in the Indian population during the past decade.[51,52,53,54,55]

Computerized tomography studies revealed brain atrophy among chronic alcohol users with an association with duration and amount of alcohol use.[56]

The visual image-induced craving for ethanol (VICE) protocol, a reliable and valid measure of alcohol craving, was developed.[57] It is a symptom provocation tool for functional magnetic resonance imaging (fMRI) experiments.

Imaging research in adolescents with familial AUD has revealed age-related differences in the maturation of several higher-order association cortices that are critical to ongoing development in executive function, emotion regulation, and social cognition.[58] Therefore, it is crucial for early supportive intervention to delay alcohol initiation during this critical phase. Among individuals dependent on alcohol, fMRI-based studies revealed similar deficits in executive functioning with associated deficits in frontal and other related regions.[59,60]

A study using SPECT imaging on 20 AUD patients reported reduced frontal lobe perfusion and a long duration of drinking.[61] Around 50% of AUD patients with executive dysfunction, as measured by WCST, showed reduced perfusion on SPECT. Another study on 20 AUD, opioid use disorder (OUD), and healthy controls each found significantly lower DAT availability, as measured by SPECT/CT, in brain regions of the striatum and putamen in patients with AUD compared to OUD and controls. The AUD patients with DAT1 promoter methylation had low TRODAT-1 uptake.[62]

Other biological markers

Biological markers based on EEG and heart rate variability have been studied.[63] A small study on 27 male subjects reported an attenuated response to standing regarding delta high-frequency and low-frequency heart rate variability in AUD patients.[64] Another study from NIMHANS Bengaluru on 20 male AUD patients and 18 controls reported significantly lower time and frequency domain measures of sleep heart rate variability among AUD patients than controls.[65]

Psychological factors

Psychological factors also play a significant role in alcohol use initiation and maintenance. A study in Jharkhand reported high emotional problems, societal pressure, and acceptance as significant reasons for alcohol use.[66] One study from South India reported lower motivation levels among those seeking treatment for AUD.[67] However, the motivation improves significantly over a short inpatient treatment course. Such motivation is associated with various factors, including the severity of AUD, complications, onset, religion, and referral mode. Another study reported that the earlier onset of alcohol use is associated with chronic heavy drinking in AUD patients.[68] Nadkarni and colleagues (2012) undertook a study to explore the explanatory models and coping strategies of AUD patients and their significant others.[69] They reported that AUD and consumption are associated with psychosocial stress, peer pressure, pleasure, and availability of disposable income. Another study included 40 AUD patients and compared them with 40 healthy controls and reported that AUD patients had higher anger expression and lower self-esteem than controls.[70] ‘Anger out’ was significantly correlated with the severity of alcohol dependence. It is also reported that life skills and attitudes toward alcohol consumption predict academic achievement among students.[71] The Triguna model of personality has been explored in the context of AUD. A recent study included 85 male patients with AUD from NIMHANS Bengaluru.[72] The study suggested higher scores of Tamas, neuroticism, and negative affect among those diagnosed with AUD. Those without AUD scored higher on Sattva, extraversion and conscientiousness, positive affect, and life satisfaction.

Sociocultural factors

Social factors play a significant role in initiating and maintaining alcohol consumption. For example, a qualitative study from South India suggested that though alcohol use is part of a culture, the easy availability of alcohol in government-run shops and the introduction of stronger Indian-made foreign liquors (IMFLs) have changed consumption from festivals to drinking more often.[73] The study and others further indicate a decrease in the age of onset of alcohol use and AUD.[74] It is well known that alcohol exposure in movies is associated with higher rates of alcohol consumption, especially among adolescents and young adults. A recent study tried to assess rates of alcohol use depiction in Bollywood movies. The authors included each year’s top five grossing movies from the three selected decades. The authors found an increasing trend in portraying alcohol consumption by positive characters for fun and relaxation in Bollywood films.[75]

Stigma toward alcohol use is prevalent in India and has also been analyzed in a few studies. A recent qualitative study from Goa suggested that stigma is a significant barrier to seeking treatment and has a detrimental impact on the caregiver’s psychological health and caregiving.[76] Such stigma is prevalent in homes, health systems, and healthcare places and takes the form of ignorance and discrimination. Another study from the same group suggested that families of patients with AUD have less opportunity for saving, more job instability, and poor treatment opportunities.[77] As per one study conducted in North India, the stigma reported by AUD patients is higher than those with OUD.[78] Duration of AUD, employment status, and current abstinence are important predictors of stigma. The perceived stigma of alcohol use is higher among those from rural backgrounds.[79] The stigma of alcohol use has also been studied among special populations such as men with HIV/AIDS.[80] One study analyzed the mediating effects of HIV-related stigma between alcohol use and health-related quality of life (HRQoL). The study reported that around 27% of the impact of alcohol use on HRQoL was mediated by HIV stigma.

CLINICAL PROFILE AND CORRELATES OF DRINKING

The profile of patients with AUD and correlates of drinking have also been studied in the Indian population.[81,82] A study was conducted in urban areas of Tamil Nadu to document the pattern of alcohol consumption among the adult general population. The authors reported that among 400 study participants, 156 were using alcohol. Among these, 67% had a problematic drinking pattern, 52.5% had a harmful/hazardous drinking pattern, and around 15% suffered from AUD. Problem drinking was associated with illiteracy, comorbid tobacco use, and being single/divorced.[83]

Pathways to care were studied using the WHO encounter form varied across populations; in the southern population, only 5.5% sought direct help, whereas a study from Delhi observed that addiction treatment centers are the first contact for half of the treatment-seeking population.[84,85] In the treatment-seeking sample, it is reported that the age of first drink is around 18.93 years, while the age of onset of dependence is around 28.28 years.[86] Pillai et al.[87] 2014 study suggests a substantial increase in adolescent drinking onset in more recent birth cohorts. Consistent with other countries, teenage drinking onset increases the likelihood of lifetime alcohol dependence, hazardous or harmful alcohol use, alcohol-related injuries, and psychological distress. Patients with alcohol dependence are likelier to be unemployed. A study from a tertiary care hospital in Bengaluru reported that the age of initiation of alcohol use had a negative correlation with the severity of AUD.[88] The study also found that the age of initiation of the first drink was a better predictor of AUD severity than the family history of AUD.

On the other hand, the density of family history and AUD severity were positively correlated. Among those without medical comorbidities, the lifetime consumption of alcohol was positively correlated with the severity of AUD.[89] Another study tried to understand the subtyping of alcohol dependence among Indian male patients using cluster analysis.[90] They found two different clusters of AUD patients: one with antisocial personality disorder (ASPD) and conduct disorder (CD) or the externalising disorders and the other without ASPD/CD or the nonexternalizing disorders.

Studies have also looked into the clinical profile of women who drink alcohol. As per one audit done in South India, almost 80% of women who seek treatment for substance use disorders (SUDs) have AUD.[91] Another study from the same site reported that the women initiated alcohol use in their early twenties, and AUD was developed by the age of around 30 years. The level of AUD severity was high in the sample. However, the study was done on only 35 women AUD patients.[92] On the other hand, a 5-year chart review from North India reported that only around 10% of women seeking SUD treatment report alcohol as their primary substance.[93] Similar rates have also been reported among adolescent girls seeking SUD treatment.[94] Thus, there might be regional differences in patterns of alcohol and other substance use across India.

Finally, the drinking patterns have also been studied in patients with alcohol-associated liver disease patients. As per one study, those with cirrhosis drink significantly higher than those without cirrhosis.[95] They are also more likely to drink alone, outside meal hours, and in heavy episodic patterns.

Alcohol use and craving

Craving is an integral part of processes that underly AUD development. A study conducted on 30 patients with AUD in North India reported that craving is an important factor associated with relapse.[96] Another study from South India using similar tools reported that high craving was associated with fewer nondrinking days.[97] Irrespective of abstinence during follow-up, craving was reduced significantly over the period. Finally, the level of craving at baseline was negatively correlated with proximal abstinence days.

Alcohol withdrawals

Alcohol withdrawal management is one of the most important parts of overall AUD management. However, it is insufficient as most patients require long-term maintenance treatment. Almost 65% of patients have unfavorable outcomes after (only) community detoxification.[98]

Studies have been conducted to understand various aspects of alcohol withdrawal. As per one small case-control study, oxidative stress parameters change throughout withdrawals.[99] However, they are not associated with alcohol withdrawal severity.

Complicated alcohol withdrawal has also been studied. It has been reported that heavy drinking, continuous drinking, previous history of delirium tremens, alcohol-induced psychosis, and cognitive deficits are all significant predictors of complicated alcohol withdrawals, especially delirium.[100] It is seen that almost 1% of patients admitted with AUD have a history of alcoholic hallucinosis.[101] Among these, around 42% have a family history of psychosis. Auditory hallucinations are the most common symptom in around 95% of patients with a history of alcoholic hallucinosis.

ALCOHOL-ASSOCIATED HARMS

Impact on self and family

Several Indian studies have explored the harmful impact of AUD on individuals and family members. Studies report that people with AUD, especially women, are likely to experience a relatively high number of stressful events compared to controls.[92] Furthermore, longer duration and severity of AUD have been associated with high-risk behaviors and negative consequences.[102,103,104] In a study, among patients with AUD, around 21% reported a history of road traffic accidents, while around 17% also reported involvement in risky sexual behaviors.[104] These associated harms significantly impair quality of life and lead to disability in various domains.[105,106,107,108]

Indian studies show that drinking behaviors often put a significant burden on the family. In a study from North India, over 95% of the families reported experiencing caregiver burden.[109] Findings suggest that higher scores on alcohol-related consequences contribute to poor employment status and an increased percentage of family income spent on procuring alcohol.[110] According to a multicountry community survey, households with a member with AUD had lower levels of adult education, lower housing standards, total household income, higher healthcare expenditure, and greater use of poor financial coping strategies.[111] These conditions lead to fewer savings and poor treatment opportunities to aid recovery, eventually trapping individuals and limiting opportunities to overcome dependence.[77] Those using alcohol are likely to have behaviors causing significant distress to the family, leading to strained relations with their family members and neighbors.[112,113]

Impact on spouses

According to a multistate household study in India, over 83% reported experiencing at least one alcohol-related harm from a heavy drinker.[114] Among the family members, spouses and children are the most impacted group due to alcohol use.[115,116,117,118] Husband’s drinking behavior puts a significant caregiver burden on the spouses, contributing to stress and poor marital and sexual satisfaction and general quality of life.[119,120] According to a national survey, women whose husbands consumed alcohol had higher odds of experiencing physical, sexual, and emotional violence.[121] The prevalence of interpersonal/domestic violence varies from around 16% in community studies to 60–80% in wives of patients with AUD seeking treatment.[122,123,124] IPV due to alcohol use is associated with increased levels of stress. It leads wives to resort to various maladaptive (sexual withdrawal, avoidance, taking unique action) and adaptive (indulgence, discord, assertion) coping strategies.[125] Prevalence of psychiatric comorbidity in spouses is widespread (60–80%), with adjustment disorder, anxiety, and depression among the most frequently experienced conditions.[123,125,126] Also, there are increased odds of suicidal behaviors and ideations.[124] Spouses also tend to exhibit lower resilience and higher suicidal behaviors than controls.[127,128] Several sociodemographic (lower education, unemployment, lower income)[123,129] and clinical factors (alcohol use, longer duration)[121,122,125] act as a predictor of IPV, which in turn significantly impact the resilience[127,130,131] and contribute toward psychiatric morbidity in the spouses.[124,125,127,128] Family support, successful participation in treatment for AUD, and involvement in supportive groups have been reported to have a positive impact on psychiatric comorbidity and the burden of caregivers.[122,127,132]

Impact on children

Some community and hospital-based studies indicate that alcohol use by fathers can lead adolescents to experience psychological, physical, and financial harm.[133,134,135] There are gender differences in terms of harm experienced.[133] These negative experiences, in turn, increase the odds of neurodevelopmental deficits, intellectual problems, substance use, psychological distress, suicidality, sexual abuse, and externalizing symptoms in children and adolescents.[134,136,137,138,139,140,141] Children with in utero exposure to alcohol are likely to show significantly more minor physical anomalies, philtrum smoothness, behavioral problems, and poor intellectual functioning.[142] Early adversity in children due to alcohol dependence in fathers is associated with blunted cortisol reactivity, increased site-specific CpG DNA methylation at the SLC6A4 gene, and high externalizing behavior.[136]

Psychiatric comorbidity

The lifetime prevalence of psychiatric comorbidity in alcohol dependence has been reported as very common in Indian studies.[143,144] Current prevalence varies from 32% to 59%, depending on the assessment.[105,143,144] The most common psychiatric comorbidity reported in these studies is tobacco dependence (37%–100%), followed by anxiety (5%–40%) and affective disorders (12%–29%) in males, with affective disorders being more common in females (48%).[145] Independent comorbid psychosis and alcohol-induced psychosis have only been reported in a minority (2.5% and 3.75%, respectively) of the clinical population.[143] Studies report a high prevalence of deliberate self-harm in this population, with wide variation between self-harm attempts among males (62%) and females (11%).[145,146,147] Among people with psychiatric disorders, alcohol is most likely associated with organic mood and anxiety disorders and suffers from more significant life events but not with schizophrenia.[148,149,150]

Studies have explored personality profiles of patients with AUD in comparison with the general population, opioid dependence syndrome, and HIV.[151,152,153,154] Diagnostic interview studies have reported lower prevalence (3–6%)[105,144] than studies using specific personality tools (40% to 56%). Among the personality disorders in AUD male patients, the most commonly reported include antisocial (15–26%), paranoid (9%), and avoidant personality disorders (7–13%), with borderline and dependent personality reported as the lowest.[143,155] In comparison, among females, borderline personality seems to dominate (17%).[145] Further studies exploring externalizing traits in ADS show that close to 25% have features of ADHD.[156] Comorbidities, including externalizing and personality disorders, are significantly likely in individuals with early onset dependence and higher alcohol intake [Table 2].[144,155,157]

Table 2.

Summary of studies on psychiatric comorbidity in patients with alcohol dependence

Author, year		Study Characteristics		Findings
Desai et al., 2017[157]		Hospital-based comparative cross-sectional study on 35 patients with alcohol dependence syndrome (ADS) and 369 first-degree relatives (FDRs) from South India		28.4% of patients had attention deficit hyperactive disorder (ADHD)/residual symptoms, compared with 25% of FDR. Early onset was likely to be associated with ADHD symptoms in both groups with odds being 16 times greater in patients with early onset dependence.
Samal et al., 2022[156]		Hospital-based cross-sectional study on 210 SUD from North-East India		Prevalence of ADHD in the sample was 24%. Patients with opioid use disorder had higher probability of ADHD than AUD (28.7% vs 11.5%)
Gauba et al., 2016[143]		Hospital-based cross-sectional study on 80 male outpatients with ADS from North India		Overall, 69 participants (86.8%) had a comorbid psychiatric disorder, the most common being nicotine dependence (78.75%), followed by affective disorders (28.75%), panic disorder (17.5%), generalized anxiety disorder (13.75%), phobic disorders (10%), and OCD (3.75%). A total of 45 patients (56.25%) had comorbid PD: antisocial (15.0%), paranoid (8.75%), and avoidant (7.5%). The least common were borderline (2.5%) and impulsive (2.5%).
Arya et al., 2016[105]		A hospital-based cross-sectional study on 100 male ADS inpatients from North India		Current psychiatric comorbidity was reported in 32% of the sample. Anxiety (13%) and depression (12%) were among the most common comorbidities, followed by BPAD (4%), ASPD (6%), and panic disorder (2%).
Pandiyan, 2012[158]		Hospital-based cross-sectional study on 100 female sex workers from South India		Seventy-eight patients reported suffering from physical and psychological illness, respectively. Other comorbidities included tobacco use (74%), opioid (14%), hepatitis (14%), and STD (19%)
Saha 2017[149]		Hospital-based cross-sectional study on 100 psychiatric inpatients vs 100 controls		Patients with psychiatric illness were likely to be dependent on alcohol and experience greater life events compared to controls
Basu 2013[107]		Retrospective study on patients with dual diagnosis from North India		Among the patients with dual diagnosis, 15% had current alcohol use, which in turn was most likely to be present with organic, mood, and anxiety disorders
Das 2020[159]		Hospital-based cross-sectional study on 57 outpatients with ADS		The lifetime and current psychiatric comorbidity was reported in 84% and 59%, respectively. Among current comorbidities, tobacco was common (37%), followed by depression (12%), anxiety (5%), drug use (10%), ODD (10%), and ASPD (3.5%) Comorbidity was higher in early onset group
Balachandran, 2023[155]		Hospital-based cross-sectional study on 100 inpatients with ADS from South India		Prevalence of any personality disorders was 48%. Patients with comorbid PD were likely to have a lower age of drinking initiation and a higher alcohol amount
Quraishi 2013[160]		Hospital-based cross-sectional study on 150 outpatients with ADS from North India		The mean age of the study sample was 37.6±10.44 years. Tobacco was reported in 100% of cases and as the gateway drug in 90%. Exclusive bidi use was reported in 42% of the subjects. The mean duration of bidi and comorbid alcohol use was higher than that of cigarette or smokeless tobacco use.
Malik 2017[145]		Hospital-based cross-sectional study on 35 female inpatients and outpatients with ADS from South India		20 patients (57.14%) met the criteria for another co-occurring Axis I psychiatric disorder. Major depressive disorder (MDD) (34%) was the most common co-occurring Axis I disorder, followed by other mood disorders such as dysthymia (11%) and mania (3%). PTSD (9%) and adjustment disorder (8%) were present in a few patients. Out of four patients (11.4%) with current suicidality, three were at high risk and one was at moderate risk for suicidal behaviors. On SCID-II, the majority of the patients (n=29) did not meet the criteria for Axis II disorders (83%). The remaining six patients (17%) met the criteria for BPD
Rahoof 2021[146]		Hospital-based cross-sectional study on 47 male inpatients with ADS from South India		Out of 47 patients, 29 reported having suicidal ideations (62%). Suicidal ideation was more among persons belonging to the below poverty line, a lower education level, unemployed, married, living with family of origin, nuclear family, urban, and using tobacco.

Medical comorbidity

In a community study, one-fifth of the respondents with AUD had a chronic health problem.[113] A clinic-based study on a sample of patients of alcohol liver diseases with alcohol dependence reported over one-fourth of patients suffering from cirrhosis.[161] In a sample of female sex workers with AUD seeking treatment, one-sixth had hepatitis and sexually transmitted diseases (STDs).[158]

AUD is a significant risk factor for stroke in elderly prediabetic individuals.[162] Another study showed that alcohol dependence is also associated with autonomic dysfunctions, showing attenuated cardiac vagal and sympathetic responses to postural changes.[64] Studies exploring metabolic syndrome have reported similar prevalence in both alcohol (20–27%) and opioid dependence (20–29%),[163,164] which in turn was found to be lower than the general population (30%).[165]

People with AUD have poor oral health and cutaneous lesions.[166,167] A retrospective study of around 3000 patients from a tertiary center reported the prevalence of pellagra at around 1% in ADS.[168] Among the clinical triad of pellagra, 100% exhibited dermatitis, 58% had delirium, and only 19% had diarrhea. These patients also had numerous associated conditions like peripheral neuropathy, Wernicke’s encephalopathy, and seizures. Persons with AUD with a decade of alcohol consumption were found to have an increase in the prevalence of mild-grade vertebral fractures, mainly in the thoracic region.[169]

Sexual dysfunction in AUD has been explored in many Indian studies with evidence that sexual dysfunctions are common in these populations, with prevalence rates varying from 37% to 62% among outpatients and even higher in inpatients.[170,171,172] The types of sexual dysfunction include erectile dysfunction (ED) (28%–70%), reduced drive (42–61%), difficulty in arousal (38–62%), reaching orgasm (13–52%), and dissatisfaction with orgasm (15–55%).[173,174,175,176,177] More than half of the females presenting with AUD are likely to present with sexual dysfunction, including decreased sexual desire and difficulties with orgasm.[178] Despite such high prevalence, over 85% of patients show improved sexual dysfunctions with abstinence.[179,180] Poor sexual dysfunction and improvement over a period is associated with alcohol-related factors (higher amount, duration, and severity) and medical comorbidities (hypertension, diabetes, alcohol liver diseases) but not with marital adjustment, depression, or anxiety.[170,172,174,175,177,178]

Recently, detoxified patients have been likely to exhibit mild cognitive impairments compared to controls[181,182] but much less than those with chronic schizophrenia.[183] The presence of comorbid alcohol use can deteriorate cognitive functions in schizophrenia.[184] The domains impacted by ADS include motor, tactile, visual, receptive, and expressive speech, reading, writing, arithmetic, and memory.[183,185] These patients will likely have lower cognitive, affective, and total empathy levels and poor emotional regulation.[186] Early-onset dependence and longer duration of alcohol intake are associated with more significant cognitive dysfunction,[61,159] which in turn can lead to impaired decision-making and poor motivation toward treatment.[187,188]

LABORATORY-RELATED RESEARCH

The research during this period aimed to understand the association between laboratory biomarkers and alcohol dependence severity. Specifically, the focus was on cortisol,[189,190] brain-derived neurotrophic factor,[191] carbohydrate-deficient transferrin,[27] ethyl glucuronide (ETG),[192] ethyl sulfate (ETS), and liver function tests [Table 3].[193,194,195,196,197,198] Electroencephalogram correlates of alcohol dependence were also the areas of interest.[199] Traditional practitioners have been found to dispense medication containing disulfiram.[200] Urinary diethylamine has been studied to understand compliance with disulfiram.[201]

Table 3.

Summary of laboratory biomarker-based research in India

Author		Details of the study		Main findings
Yadav et al. 2022[202]		Association between SAQ-C severity with serum cortisol, hemoglobin, mean corpuscular volume, LH, FSH and testosterone, liver function test.		Elevated serum cortisol with the severity of ADS
Sharma et al. 2011[200]		Four samples of the traditional products		Presence of disulfiram products sold by traditional healers for alcohol dependence. Dangers of disulfiram ethanol reaction and its complications among alcohol users have been highlighted.
Madhubala et al. 2013[203]		Case control study, various biomarkers of alcohol use among patients with alcohol use with healthy controlled subjects.		Carbohydrate-deficient transferrin better biomarker compared to GGT in terms of sensitivity and specificity
Quraishi et al. 2022[204]		Biochemical parameters in alcohol dependence vs opioid dependence vs healthy controls		Derangement in liver function test and electrolytes found in ADS and ODS compared to healthy controls
Pavuluri et al. 2022[205]		Alcohol dependence syndrome patients with healthy controls.		The activities of zinc and magnesium have been noted to be significantly lower among ADS patients compared to controls
Quraishi et al. 2019[206]		Filter paper matrix for evaluating alcohol biomarkers in the opioid using population.		90% of alcohol biomarkers were detected using the filter paper matrix; it can be a potential tool for community screening of harmful alcohol use
Shukla et al. 2017[207]		Ethyl glucuronide as an indicator of recent alcohol consumption.		At 45 ng/ml, could detect recent moderate–heavy alcohol consumption at a sensitivity of 85% and a specificity of 89%. Dose of alcohol and time since alcohol consumption are explained in the variance.
Chaturvedi et al. 2020[208]		Cluster of Differentiation 200 (CD200), the regulators of innate immune response during withdrawal phase		At baseline, the CD200 serum level in the alcohol-dependent group (at baseline) was significantly lower compared to healthy controls. It increased after 1-week and 1-month period.
Brammanathan et al. 2023[209]		Brain-derived neurotrophic factor (BDNF) in alcohol dependence (ADS)		BDNF is significantly lower in ADS with depression compared to ADS group or depression group
Dey et al. 2021[210]		Serum calcium during alcohol abstinence.		Serum calcium, PTH, calcitonin, and vitamin D had shown different patterns of changes during the early abstinence period

COURSE AND PROGNOSIS

In this area, the focus of research has been on understanding the factors associated with relapse and abstinence.[211] Individual, family, and environmental factors were found to be associated with relapse and abstinence from alcohol. Alcohol-related factors like age of onset of dependence, current age of seeking treatment, severity of dependence, and family history of alcohol dependence determine the treatment outcomes.[212,213,214,215,216,217,218,219] At an individual level, temperamental factors like extraversion, coping styles, factors like exposure to relapse cues, craving, locus of control (external), mood states, and anger are common reasons for relapse.[97,220,221,222,223,224,225,226] A few studies explored the role of biological markers (leptin, ghrelin) as predictors of relapse.[227,228] Interpersonal factors, social support, and occupational factors emerged as being associated with abstinence.[220,229,230,231] Treatment-related factors like retention to treatment and being on regular medications predicted treatment outcomes, including abstinence.[232,233,234] Significant life events have emerged as an important factor in recovery.[212] The factors varied across various speciality treatment settings. For example, a study comparing the factors associated with relapse between harmful users in gastroenterology and psychiatry settings was different.[235]

Further, among patients with delirium tremens, inpatient care has been associated with better outcomes compared to just emergency treatment alone.[236] Prolonged abstinence is associated with improvement in neurocognitive outcomes.[237] Among patients with live donor liver transplants, the incidence of relapse and rate of harmful drinking following was low. Donations from spouses and first-degree relatives were protective, whereas the history of regular drinking, past relapses, shorter pretransplant abstinence duration, and lack of family support significantly predicted relapse.[238]

CLINICAL ASSESSMENT TOOLS

Alcohol Use Disorder Identification Test (AUDIT) and Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) have been used as a screening tool to identify AUD in diverse community populations in Indian settings as well.[14,15,239] A Hindi and Konkani version of AUDIT and a shorter version with dichotomized responses have been developed.[240,241,242] Attempts have been made to overcome the challenges posed by patients unwilling for assessment by devising culturally relevant modifications in AUDIT and CAGE Questionnaire to use proxy reports by family members to determine AUD.[243,244] While AUDIT and SADQ measure AUD, there is evidence that these scales might be tapping into different outcomes related to alcohol use.[245] Apart from AUDIT modifications, attempts have been made to develop a vernacular screening instrument for alcohol disorder in emergency settings.[246] Scales like “Assessment of Recovery Capital” have been translated and validated into Hindi with acceptable scores.[247]

PHARMACOLOGICAL INTERVENTIONS

A majority of people using alcohol felt the need for treatment. However, the lack of accessible treatment is a significant barrier to treatment seeking.[248,249] A large proportion of alcohol users, despite sustaining harm, do not take treatment.[110] Even among people screened for AUD, a negligible proportion of patients received treatment.[250] A systematic review of pharmacological studies for alcohol dependence in the Indian context revealed that most studies focused on disulfiram before 2000, later decade on acamprosate and naltrexone. The most recent studies focused on baclofen and topiramate [Table 4].[251,252,253] The focus of studies predominantly focused on managing craving and withdrawal.[254,255,256] Only a few studies were on the management of withdrawal. Among them, a study found that baclofen is equally efficacious as lorazepam.[257] Community-based detoxification resulted in favorable outcomes in 35% of patients with alcohol dependence.[98] Recent studies focused on managing alcohol dependence using noninvasive brain stimulation [Table 4].[258,259]

Table 4.

Indian studies related to anticraving agents, disulfiram, and noninvasive brain stimulation for alcohol dependence

Author		Sample Size (n)		Type of study		Intervention		Outcome
Kumar et al. 2022[76]		n=90		Randomised control trial		Safety and efficacy of naltrexone (n=30) vs baclofen (n=30) vs acamprosate (n=30) in alcohol dependence		Naltrexone reduced craving but has side effects, baclofen safe in tolerability in liver dysfunction. Acamprosate had higher dropouts.
Roztkar et al. 2016[260]		n=113		Retrospective chart review		Baclofen (20–40mg) for craving in alcohol dependence		Reduced craving scores even in poorly motivated persons.
Jose et al. 2019[261]		n=94		Randomised control trial		Baclofen (n=49) vs topiramate (n=45) for alcohol dependence		Baclofen is better tolerated and more abstinence rates compared to topiramate
Shukla et al. 2015[262]		n=549		Retrospective study		Baclofen (348) vs acamprosate (201) for alcohol dependence. Time to relapse as an outcome		Baclofen has greater time to first drink. Dose of baclofen and average alcohol intake explain significance variance in “time to first drink”
Bhatia et al. 2022[263]		n=614		Prescription-based audit		Adverse effects among patients prescribed disulfiram for alcohol dependence		Decreased appetite followed by headache and metallic taste were commonly encountered adverse effects
Mangot et al. 2017[264]		n=268		Cross- sectional, observational study		Disulfiram/disulfiram-like products prescription patterns among patients with alcohol dependence		Around 37% (n=100) of patients received disulfiram/disulfiram-like products. Majority were given by family members surreptitiously.
Palatty et al. 2011[265]		n=51		Uncontrolled cohort study		Adverse effects with disulfiram among patients attending deaddiction services		27.4% had drowsiness, 21.4% tiredness, 7.8% skin manifestation.
Raikwar et al. 2020[266]		n=60		Single-blind randomized sham-controlled study		rTMS for alcohol dependence compared to sham 10 daily sessions over left dorsolateral prefrontal cortex		Craving did not improve
Gupta et al. 2021[267]		n=100		Randomised control trial		rTMS vs standard treatment for alcohol dependence		rTMS arm has lesser relapses
Holla et al. 2020[268]		n=24		Randomized sham-controlled study		Prefrontal tDCS (n=12) vs sham (n=12) for alcohol dependence		Increase in global efficiency of brain networks, which predicted relapse and measures of impulsivity.
Mishra et al. 2010[269]		n=45		Randomized sham-controlled study		Right dorsolateral prefrontal cortex rTMS		Significant anticraving effects

PSYCHOLOGICAL INTERVENTIONS

A proportion of research focused on managing alcohol dependence using psychological interventions. The areas of interest are motivation enhancement therapy; relapse prevention; cognitive, behavioral, and cognitive behavioral therapy models; family interventions; brief interventions;[270] and integrated models [Table 5].[271,272,273,274] Computer-delivered and technology-based interventions for AUD and hazardous drinking are of recent interest.[275,276,277,278,279] The research focused on delivering interventions using trained nursing professionals and community-level counsellors and reported them as feasible and effective.[280,281]

Table 5.

Psychological intervention studies for alcohol dependence

Author		Sample Size (n)		Type of study		Intervention		Outcomes
Nattala et al. 2010[133]		n=90		Randomized trial		Three groups of relapse prevention (RP) Individual, Dyadic (family + Individual), Treatment as usual (TAU)		Dyadic RP better than individual in reduction in the quantity of alcohol, drinking days, and family problems. Dyadic RP is better than TAU in all the domains.
Thomas et al. 2011[282]		n=44		Qualitative study using the ecological system model		4 counseling sessions for AUD in TB patients across two Chennai corporations with control arm of two corporations did not receive any intervention		TB outcomes and adherence to medication is better in the group that received intervention
Nadkarni et al. 2020[283]		n=38		Uncontrolled cohort study		Home-based detoxification and relapse prevention by lay health care workers		The protocols need to be adapted further.
Synowski et al. 2021[284]		n=512		Secondary analysis of data of multicenter single-blind randomised controlled trial		Counseling for alcohol problems delivered by nonspecialist health workers for alcohol dependence with comorbid depression along with enhanced usual care		Can be safely delivered. But the effectiveness is limited
Suryavanshi et al. 2022[285]		n=12 of AA members, n=22 Healthcare providers		Feasibility study		Novel computer-based virtual counsellor-delivered interventions for alcohol use among patients with HIV or TB Studied using focused group discussions and in-depth interviews.		The intervention is acceptable and appears feasible to implement if coupled with person-delivered intervention
Prasad et al. 2023[286]		n=360		Randomised control trial		Assist linked brief interventions vs general health consequences talk in a randomised patients with alcohol dependence		Assist linked brief interventions were effective at the end of 3 months Quality of life improved with the brief interventions
Srivastava et al. 2022[287]		n=226		Randomised control trial		CBT (n=116) vs Treatment as usual (n=110) for alcohol dependence		Relapse is lesser with the CBT compared to TAU at the end of 6 months and 1 year for alcohol dependence.
Ghosh et al. 2023[288]		n=25		Mixed-methods, pilot, and cluster randomized trial		Digital screening and brief intervention for alcohol misuse among college students		Digital screening and brief interventions are feasible, acceptable, and possibly effective among college students in low-resource settings
Singh et al. 2023[289]		n=84		Open label RCT		Cognitive therapy (n=45) vs treatment as usual (n=39) for alcohol dependence To assess for early maladaptive schemas (EMS)		EMS improved along with perceived stress in the treatment arm. But not the severity of alcohol use.
Pressy et al. 2019[290]		n=30		One-group pretest and post-test in a pre-experimental design		Emotional regulation training on stress, depression anxiety on people with alcohol dependence Pre-post design		Reduction in stress, anxiety, depression with the emotional regulation training
Rentala S et al. 2022[291]		n=100		Single-blind RCT		Integrated-Body Mind and Spirit (I-BMS) (7 sessions) vs treatment as usual for alcohol dependence		I-BMS is effective in reducing the relapse, improving motivation and well-being
Omkarappa et al. 2022[292]		n=195		A randomized controlled trial		Psychosocial intervention for internalising behaviors for children of fathers with alcohol dependence. School children were randomised to treatment and control groups		Improvement noted in the intervention arm
Sinha et al. 2022[293]		n=84		A parallel-group, single-blind study		Screening and Brief intervention (SBI) for hazardous alcohol use among patients diagnosed with mood disorders SBI vs general advise		SBI has been associated with reduction in mean AUDIT scores, frequency of heavy drinking and motivation
Yadav et al. 2021[294]		n=80		Randomized control design		Breathing and relaxation training 6-day intervention (Sudarshan Kriya) as an add on to standard therapy (n=40) vs standard therapy alone (n=40)		Improvement in WHO-well-being index and AUDIT scores at the end of 6 months.
Satyanarayana et al. 2016[295]		n=177		Randomized Controlled Trial		Integrated CBT (n=88) vs Treatment as usual (n=89) for Intimate Partner Violence among spouses of persons with alcohol dependence.		Lower IPV perpetration among the intervention group along with lower anxiety and depression scores.
Kumar et al. 2020[296]		n=50		Randomized control design with the pre-post comparison		Integrated intervention program for alcoholism (n=25) vs treatment as usual (n=25). The focus was on impulsivity and disadvantageous reward processing/risk taking in persons with alcoholism		The intervention improved these domains compared to treatment as usual
Ganavaidya et al. 2018[297]		n=83		Randomised control trial		Knowledge attitude and practices following psychosocial intervention during admission to a deaddiction centre		The knowledge, attitude, and practices improved following discharge compared to baseline
Kamal et al. 2020[298]		n=130		Randomised control trial		Nurse delivered Screening and Brief intervention (SBI) for college students vs general advise for college students with hazardous alcohol use		SBI is acceptable and has a small effect size in terms of efficacy
Ng et al. 2020[299]		n=60		Randomised control trial		Nurse-led Body Mind Spirit (BMS) relapse prevention (7 sessions) vs treatment as usual for alcohol dependence		At 3 months, reduced craving and drinking outcomes among patients with alcohol dependence.
Baby et al. 2019[300]		n=106		A pre- and postintervention study without a control group		Modified brief intervention for hazardous alcohol use at workplace		Reduction in drinking outcomes at the end of 3 months
Nattala et al. 2018[301]		n=85		A randomised control trail		Video-enabled cue-exposure-based intervention (VE-CEI) (n=43) vs treatment as usual (n=42)		Improves outcomes at the end of 6 months
Chhabra et al. 2010[302]		n=1,421		Pre- and postintervention design		School-based teenage education program (STEP) for HIV and alcohol misuse. Training of trainers in the community for reducing high risk behavior and increasing self-efficacy in Himachal Pradesh.		The intervention had a greater impact on girls; girls evidenced greater communication skills and a trend toward greater self-efficacy and reduced risk taking behavior. The STEP has been successfully adapted by the community organizations that were involved in coordinating the program at the local level.

Policy-related research

Only a minuscule amount of research was focused on alcohol policy. During political elections in a southern Indian state, “dry days” are enforced with advance notice. Two studies investigated the sudden alcohol prohibition during elections. The first study showed a more than twofold increase in delirium tremens among alcohol-dependent individuals due to unexpected bans.[303] Based on in-depth patient interviews, the second study found that increased alcohol availability before the polling day and abrupt cessation during polling days led to more relapses during campaigns and complicated withdrawals. It is concerning that nearly half of the patients did not take any measures despite being aware of the “dry days.”[304] Sood A et al.[305] (2019) found that Indian households consumed 0.18 L of alcohol per month, spending Rs. 16.46 (0.98% of total expenditure), with country liquor prevalent, especially in rural areas. Jyani G et al.[306] (2019) estimated that alcohol-related deaths would cost 258 million life years by 2050, but eliminating alcohol could gain 552 million quality-adjusted life years. Despite adjusting for tax receipts, alcohol caused a net economic loss of 1.45% of GDP/year. In another policy-related study, Balhara YPS et al.[307] (2023) assessed Bihar’s alcohol prohibition impact, finding a 41.78% decrease in male and a 69.56% decrease in female alcohol use post-prohibition. Yet, country liquor use notably increased among men.

COVID-19 AND ALCOHOL-RELATED RESEARCH

The COVID-19 pandemic was an unprecedented event in human history. The pandemic and related containment measures significantly impacted general health and addiction services.[308] The pandemic uncovered several unique challenges for patients with AUD like forced abstinence, methanol toxicity, increased withdrawal-related emergencies, and poor access to treatment services.[309,310] It had an impact on the family members.[311] Indian studies explored the impact of the sudden lockdown and closure of all except emergency services and reported decreased accessibility, increased cost, and poor quality of alcohol.[312,313] A significant increase in online searches for ways to procure alcohol was observed during this period.[314,315] Due to unavailability, people had to resort to gray markets to arrange alcohol for themselves.[312,313] An abnormal rise in people seeking treatment for complicated withdrawals was observed in the tertiary centers and rural hospitals.[316,317] Additionally, there are reports of alcohol-related suicides in India amid the COVID-19 pandemic, drawing data from recent media coverage. Complete details on 27 cases were retrieved, primarily from southern India.[318] Autopsy findings in two Indian districts studied the alcohol-suicide link during the COVID-19 lockdown and unlock phases. Alcohol use was noted in 16.8% of suicides, with the proportion linked to current alcohol use remaining comparable between the lockdown and unlock phases.[319] While a nationwide study from India provided inconclusive findings suggesting reduced alcohol use due to the pandemic, a community study from rural India reports a reduction in alcohol intake in 2/3^rd of the alcohol users.[320] Generally, people with AUD found it difficult to access treatment services. Still, compared to OUD, they were less likely to make quit attempts, seek treatment during the lockdown period, and experience more significant stigma from family members for their substance-seeking behavior. A key takeaway from the pandemic experience related to alcohol was that there is a need for a broader discussion on harm reduction approaches and alcohol policy in the Indian context.[321]

ALCOHOL-RELATED RESEARCH: FOCUS AREAS AND GEOGRAPHICAL DISTRIBUTION

Karnataka and New Delhi were the leading states in publishing alcohol-related research in India over this period. It seems intuitive as both these states have leading Central Institutes (NIMHANS and NDDTC AIIMS) in addiction research and management. The most common areas covered in alcohol-related research in India were clinical correlates, clinical management, social psychiatry, and epidemiology/public health [See Supplementary Material].

LIMITATIONS

Our search methodology did not include the use of supplementary search engines such as EMBASE, SCOPUS, Web of Science, and others. We also refrained from utilizing generic search terms like “alcohol” to avoid an overwhelming volume of results that would be difficult to sift through. Instead, we employed a focused search strategy that may have led us to miss some publications. Nonetheless, we aimed to create a comprehensive summary of alcohol-related research in India and have presented the information we could gather.

CONCLUSIONS

Indian research on alcohol has focused on diverse areas in the past decade. National surveys have led to a better understanding of the prevalence and associated factors in different regions of India. Still, there is a need to have these at regular intervals so that dynamic patterns of changes in the prevalence of AUD can be identified. While epidemiological and psychological management-related research has received maximum attention, important areas like biological research, pharmacological management, and alcohol policy need prioritization. Studies have focused on alcohol-related psychological and medical comorbidities, but only minimal research has concentrated on the longitudinal outcomes of such comorbidities. Further studies are needed to explore the role of digital technologies in the management of AUD.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

SEARCH STRATEGY

((“india”[MeSH Terms] OR “india”[All Fields] OR “india s”[All Fields] OR “indias”[All Fields]) AND (“alcoholism”[MeSH Terms] OR “alcoholism”[All Fields] OR (“alcohol”[All Fields] AND “disorder”[All Fields]) OR “alcohol use disorder”[All Fields] OR (“alcoholism”[MeSH Terms] OR “alcoholism”[All Fields] OR (“alcohol”[All Fields] AND “dependence”[All Fields]) OR “alcohol dependence”[All Fields]))) AND (2010/1/1:2023/7/31[pdat])

Translations

India: “india”[MeSH Terms] OR “india”[All Fields] OR “india’s”[All Fields] OR “indias”[All Fields]

alcohol use disorder: “alcoholism”[MeSH Terms] OR “alcoholism”[All Fields] OR (“alcohol”[All Fields] AND “disorder”[All Fields]) OR “alcohol use disorder”[All Fields]

alcohol dependence: “alcoholism”[MeSH Terms] OR “alcoholism”[All Fields] OR (“alcohol”[All Fields] AND “dependence”[All Fields]) OR “alcohol dependence”[All Fields]

Filter used: 01-01-2010 to 31-07-2023

Screening for titles by VLN and SA

Abstracts were screened by the VLN, SA, AP, DM

Full-text articles were reviewed by VLN, SA, AP, DM

National and international journals were searched independently by AP, SA, and DM.

From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71

Supplementary Table 1.

Epidemiological research in India

Author and year		Objective of the study		Important findings
Tripathi BM et al., 2010[1]		To delineate the circumstances surrounding specific geographical areas and sub-groups concerning alcohol/drug use and the risks associated with HIV/STI infections.		Easy access to alcohol and drugs, accompanied by availability of sex workers appeared as compound risk factors in the study sites.
Shukhwal M et al., 2013[2]		To investigate spirituality, religiosity, and alcohol-related beliefs among college students (n=236)		Higher levels of spirituality and religiosity, as well as specific components of religiosity (God Consciousness and Formal Practices), were associated with lower acceptance of drinking and alcoholism.

Studies on training.

A blended online training model for primary care physicians in underserved areas was studied.[3]

Supplementary Table 2.

Summary of Indian studies on factors associated with abstinence, relapse and recovery

Author and year		Objective of the study		Important findings
Ratnam et al. 2019[4]		Factors associated with abstinence and relapse among people dependent on alcohol		Factors that predicted abstinence are coping styles, life-event, and relapse-precipitant exposure
Nandyal et al. 2019[5]		Factors associated with abstinence		Regularity of follow-up, adherence to medicines and having had the habit of drinking alcohol with friends, as opposed to solitary drinking.
Soundararajan et al. 2023[6]		Craving as predictor for relapse		Higher baseline craving is associated with increased risk of relapse. Baseline craving was negatively associated with proximal percentage of days abstinent and cravings at follow-ups negatively correlated with cross-sectional abstinent days. Craving reduced significantly over time, irrespective of the drinking status in follow-ups.
Ezhumalai et al. 2022[7]		Importance of occupational factors in relapse		Self-employed, having skilled work, regular pattern of employment, monthly mode of income. Occupational factors seem to influence the outcome in alcohol dependence and appropriate vocational interventions would be effective in promoting long-term abstinence.
Soundararajan et al. 2017[8]		Personality profiles and drinking patterns		Extraversion is associated with higher drinking and a higher risk of relapse.
Saxena et al. 2011[9]		Predictive value to depression and social support among people attending alcoholic anonymous		Both of them did not predict abstinence.
Reddy et al. 2017[10]		Predictors of coping behaviour and expressed emotions in patients with alcohol dependence		Age at first drinking is identified as significant predictor of coping behaviour and level of expressed emotions.
Ghosh et al. 2023[11]		Inpatients admitted at PGI Chandigarh between 2007-2019, were studied to understand factors associated with treatment completion		Rate of treatment discontinuation was 27% People who were treated with medications had a higher odds of treatment completion compared to without medication. Patients with comorbidities have higher Odds of treatment completion.
Sureshkumar et al. 2017[12]		Factors associated with abstinence		Coping behaviour plays an important role in relapse
Sharma et al. 2017[13]		Factors associated with abstinence		Anger has been identified as significant predictor of abstinence
Dixit et al. 2015[14]		Factors associated with abstinence		Social support is an important predictor of abstinence.
Nadkarni et al. 2013[15]		Factors associated with abstinence		Attrition is higher among people with alcohol use disorders compared to abstainers or casual drinkers
Chauhan et al. 2018[16]		Factors associated with relapse compared to people who were abstinent		Positive family history of substance use, past history of alcohol-related comorbidity, experienced a higher number of undesirable life events, and higher negative mood states and social anxiety and dysfunction in social, vocational, personal, family, and cognitive spheres compared to patients who had remained abstinent.
Nadkarni et al. 2017[17]		Two cohorts were studied 2006-2008 and 2012-2014. Trajectories of recovery and incidence were studied.		Recovery has found to have several benefits in health and social domain.
Nagappa et al. 2020[18]		Prevalence of willingness to quit and factors associated with it		59% of people who use alcohol are willing to quit. Education, occupation, higher AUDIT scores, frequency of alcohol use, and positive family history of alcohol-related illness were significantly associated with willingness to quit alcohol.
Anand et al. 2023[19]		A qualitative study to understand the perspectives, barriers and facilitators for men with substance use disorders		Individual factors, and interpersonal systemic factors were the facilitators of recovery. Regarding the perspectives of recovery include various goals concerning substance use, lifestyle, personal growth, and the role of family and ecological factors. There are multiple barriers identified, including stigma.
Kaur et al. 2023[20]		Assess the differences between correlates of recovery capital between the patients with opioid dependence and alcohol dependence		Social support has been identified as an important factor In both the groups Coping style and other lifestyle factors contribute to recovery

Supplementary Table 3.

Indian studies on quality of life and disability

Author and year		Objective of the study		Important findings
Shadakshari et al. 2022[21]		Qualitative study among 21 substance using physicians to understand occupational challenges secondary to substance use disorders		Direct consequences of the psychoactive effect of the substance, adverse effects on clinical care and service delivery, impairment in regularity and punctuality, changes in the physicians’ behaviours, changes in the work environment and diverse responses of colleagues and the hospital administration toward substance use-related actions, ethical issues at workplace, and effects on career growth.
Patkar et al. 2019[22]		Study assessed the association of severity of alcohol dependence with the quality of life and the disability		Alcohol dependence is associated with lower QoL and higher levels of disability levels. The severity of alcohol dependence is inversely proportional to the QoL experienced by them and directly proportional to their disabilities.
Basu et al. 2019[23]		Psychometric properties of hindi translated version of “Assessment of recovery capital” scale		It has been identified as a acceptable scale and can be used for recovery oriented addiction treatment services.

Broad themes of included studies:

Supplementary Table 4.

Broad themes of studies included

Type of Study		Number of studies
Clinical correlates		61
Clinical trials/management		58
Mechanism/Translational		51
Social psychiatry		38
Epidemiology/Public health		38
Outcomes/prognosis		25
Others		16
Medical psychiatry		14
Imaging		12
Scales		7
Grand Total		320

State-wide distribution of studies: This table represents a broad overview of where the proportional research output is evolving. There might be a possibility of missing out on some states due to inherent search strategy and exclusion.

Table 5.

Broad division of state-wise distribution research (top 10 states/union territories only)

State or Union Territory		Publications
Karnataka		71
Delhi		58
Maharashtra		29
Chandigarh		27
Goa		19
Kerala		13
Jharkhand		12
Puducherry		12
Tamil Nadu		11
Uttar Pradesh		7