India has been under nationwide lockdown since 25 March 2020. The lockdown includes prohibition on sale of alcohol, restrictions on movement, and limited availability of public transportation. The countrywide lockdown has posed unique challenges to those with alcohol use disorder: both active alcohol users and those seeking treatment to quit. 1
We contacted patients who were enrolled in an ongoing project assessing the impact of disulfiram among patients with alcohol use disorder. The research project was approved by the Institutional Ethics Committee and conformed to the provisions of the Declaration of Helsinki. The patients gave informed consent and their anonymity has been preserved. Telephonic reminder calls were made to the participants to ensure therapeutic adherence and to obtain updated information on alcohol use.
We were able to connect with 73 (76.7%) of the patients. All were male. The mean duration of alcohol use disorder was 8.66 (SD 6.20) years.
Alcohol and tobacco products were not included in the list of essential commodities during the lockdown. This has meant non‐availability of these substances through authorized vendors. However, around 20% (n = 16) of the patients reported that they had tried to procure alcohol during lockdown and 10 of these (62.5%) had successfully procured alcohol at least once (Table 1). Most of them have done so through clandestine sources and at higher prices than normal. Additionally, alcohol procured by about 20% of these 10 patients had been sold in an unsealed bottle. This raised concern about the safety of these alcoholic beverages and the possibility of exposure to additional health risks from consumption of adulterated or surrogate alcohol (e.g., poisonous fungus, methanol toxicity). 2 , 3
Table 1.
Alcohol use pattern and help‐seeking behavior of persons with alcohol use disorder during the COVID‐19 lockdown period (N = 73)
| Alcohol use pattern and help‐seeking behavior | n (%) | |
|---|---|---|
| Tried to procure alcohol since lockdown | 16 (21%) | |
| Was able to procure alcohol since lockdown | 10 (62.5%) | |
| Source of procurement of alcoholic beverage (n = 10) | Gray market | 7 (70%) |
| Friends | 2 (20%) | |
| Employee from work | 1 (10%) | |
| Pricing of the alcoholic beverage | Higher | 9 (90%) |
| Free | 1 (10%) | |
| Alcoholic beverage was sold in a sealed bottle | 8 (80%) | |
| Tried to attend follow‐up at NDDTC since lockdown | 28 (36.8%) | |
| Could reach the treatment center | 5 (17.8%) | |
| Reasons for not being able to reach treatment center (n = 23) | Restrictions on movement | 7 (30.4%) |
| Could not arrange transport | 10 (43.4%) | |
| Decided not to travel due to safety concerns | 5 (21.7%) | |
| Could not get leave from work due to emergency duties | 1 (4.3%) | |
| Tried to procure disulfiram since lockdown | 15 (19.7%) | |
| Able to procure disulfiram since lockdown | 9 (60%) | |
| Source of procurement of disulfiram (n = 9) | Chemist | 8 (88.8%) |
| Physician | 1 (11.1%) | |
| Experienced alcohol withdrawals since lockdown | 5 (6.6%) | |
| Management of the alcohol withdrawals (n = 5) | Procured medicines from chemist | 1 (20%) |
| No intervention | 4 (80%) | |
| Used any tobacco product since lockdown | 38 (50%) | |
| Source of procurement of tobacco product (n = 38) | From vendor at higher price | 33 (86.8%) |
| From vendor at sale price | 2 (5.2%) | |
| Had stocked before lockdown | 1 (2.6%) | |
| From friends | 2 (5.2%) | |
| Family members could be contacted over the telephone | 34 (44.7%) | |
NDDTC, National Drug Dependence Treatment Center.
Five patients (6.6%) reported having experienced alcohol withdrawal since the beginning of lockdown and one of these subjects reported experiencing withdrawal seizures. Only one patient of the five (20%) has been able to procure medicines to manage the withdrawals, and most of the subjects have not been able to access any medical help to manage their withdrawals.
The proportion of alcohol users across the country who would have experienced withdrawals is likely much higher than what we have observed in the current study. This is so because subjects in the present study had been offered treatment for alcohol use disorder in the past and it is likely that a significant proportion of them was no longer using alcohol, at least on a regular basis. While withdrawal symptoms among those physically dependent on alcohol are self‐limiting, they are distressing and can even be lethal if left untreated. The added mental stress due to uncertainty about the future due to COVID‐19, hardships faced due to lockdown, and economic and employment concerns would have made it even more challenging to bear the withdrawals. The bidirectional relation between coexisting psychological distress and increased alcohol withdrawal symptom severity has been well established in the published literature. 4 , 5
Of the 15 patients (19.7%) who tried to procure disulfiram, only nine (60%) were able to do so. Lack of availability of disulfiram at pharmacies is a concerning observation. Similarly, medications for the management of alcohol withdrawal symptoms could be procured by just one of the subjects. Concerns about limited attention to the availability of such medicines have been reported in the literature. 6
A total of 28 (36.8%) patients tried to attend follow‐up at the treatment center. Only five of these (17.8%) were able to reach the center. Lack of transportation, restrictions by law‐enforcement agencies, and fear of contracting COVID‐19 infection during travel were the common barriers to treatment‐seeking (Table 1). A reduced help‐seeking behavior out of safety concerns has been reported during previous pandemics as well. 7 While it is likely that the complete lockdown will be lifted in the coming weeks, the restrictions on movement are likely to continue further. Hence it is important to ensure the availability of public transportation as well as support from the law‐enforcement agencies to facilitate the movement of these patients to the treatment centers. Moreover, treatment‐seeking will remain low despite the lifting of restrictions unless the safety concerns of this group are addressed adequately.
In a binary logistic regression model, number of days since last use of alcohol (odds ratio, 0.90 [95% confidence interval, 0.84–0.97], P = 0.007) was the only variable independently associated (inverse association) with attempt to seek alcohol during the lockdown period.
There is a need to address barriers to help‐seeking going ahead as we continue to deal with COVID‐19 in the coming months. A contingency plan should be put in place to ensure continuity of care for persons with alcohol use disorder in such extraordinary situations.
Disclosure statement
None declared.
Acknowledgment
We acknowledge the support of Professor Ravinder Goswami, Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi; and Professor Ramakrishnan Lakshmy, Department of Cardiac Biochemistry, AIIMS, New Delhi. The project was funded by the Department of Biotechnology, Ministry of Science and Technology, Government of India, New Delhi, India through a research grant.
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