How Do Individuals with Alcohol Use Disorders Think About and Respond to Election Dry Days?

To the Editor,

“Dry days,” in which the sale of alcohol is prohibited, are enforced in different states in India. These are usually related to important public holidays. Political elections also invoke “dry days,” which are usually notified in advance.

Individuals with alcohol use disorders (AUD), who represent 5.2% of the population between the ages of 10 and 75 years in India, ¹ may be affected by sudden changes in alcohol availability. ² A previous report from our center showed an increase in the number of complicated alcohol withdrawal before state elections. ³ However, it did not study the knowledge and attitudes of individuals with AUD about these contextual factors.

The general election in Karnataka was held on April 18th and 23rd, 2019 (in two phases), and there was a 48-hour prohibition of alcohol sale before each phase of polling. Hence, patients who are residents of Karnataka and presented to the psychiatric emergency services with alcohol-related clinical presentations (n = 31) between April 17th and 26th were interviewed. We evaluated whether the patients perceived changes in alcohol availability and were aware of election-related “dry days.” This was done by prospectively asking a few additional questions about the pattern of alcohol use prior to their current visit. Further, we also documented the effect of change of availability of alcohol on clinical presentations. Institute Ethical Committee approval was obtained for the study.

The socio-demographic details and clinical presentations are shown in Table 1. Almost half the sample reported an increased availability of alcohol during the pre-election period. Eleven patients (35%) had relapsed to alcohol use in the run-up to the elections, after having been previously abstinent. Nine among them had received alcohol or money during campaigning. Even during the election ban, 19 (64.5%) were able to consume alcohol at least once. Of these, four (22%) had stored alcohol before the ban; three (16%) each procured in “black” or from a neighboring state.

Table 1.

Socio-demographic and Clinical Details of the Sample (n = 31)

Characteristics	Level	Value
Age	Median age (in years)	36.5
Sex	Male (n, %)	31, 100%
Socio-economic status	BPL (n, %)	18, 58%
Region	Urban Bangalore Rural Bangalore Other parts of Karnataka	16, 52% 5, 16% 10, 32%
Case entry	New case (n, %)	13, 42%
Reason of presentation	Intoxication (n, %) Simple withdrawal (n, %) Complicated withdrawal (n, %)	11, 35% 3, 10% 17, 55%

BPL – Below Poverty Line

A majority of patients (n = 27, 87%) were aware of the election-related “dry days.” Of them, one-third learned about it from friends, while the rest of them got the information from wine shops, news, or social media. Among those aware of the “dry days,” 12 (44%) did not take any preemptive action despite knowing the same. However, we did not explore the specific reasons behind the same, which is a limitation. A majority (n = 24, 77.4%) of patients supported the election ban, while the remaining were either not sure or were against it. Those in favor of election-related “dry days” believed that it would decrease political violence during that period. Of the patients interviewed, 18 (61.3%) attributed their emergency visit to election-related “dry days.”

Further, we observed that the proportion (n = 20/48, 41.7%) of the total substance use emergency presentations due to delirium tremens was more during the study period when compared to the same period in the preceding month (n = 14/56, 25%). This hints at the fact that there may have been an overall increase in alcohol withdrawal-related presentations; however, these findings should be interpreted with caution.

Based on our results, there seems to be a change in the supply of alcohol, with an increased availability before polling day and a sudden stoppage during polling days, as reported by patients. This was also noted in reports in the popular media based on data from the Election Commission of India. ⁴ This was seen to lead to an increased number of relapses during election campaigning and complicated alcohol withdrawals during polling days.

This study mirrors results from the previous study from our centre. ³ It contrasts with findings from Brazil, ⁵ where election-related prohibition was associated with fewer acute alcohol-related presentations, including road traffic accidents. However, the occurrence of alcohol withdrawal presentations was not specifically explored in this study. Relapse among individuals with AUD is known to be related to intrapersonal and interpersonal determinants, among other factors. ⁶ We contend that elections are a critical environmental factor that may have unanticipated consequences in this population. Systematic modeling of the influence of such external contexts over time is required.

Our results also suggest an increased number of cases who presented with delirium tremens during this period. Untreated delirium tremens is associated with mortality rates up to 15%, ^7,8 which can be reduced to less than 1% with early and appropriate intervention. ⁹ So, it is critical that doctors at all levels of the health system be equipped to manage such cases.

A majority of patients knew about the “dry days,” but it is worrisome that almost half of them did not take any steps to deal with the situation. Therefore, it becomes vital for patients with AUD and their families to be educated about the risks of medically unsupervised sudden reductions in alcohol use. This could take the form of an advisory to contact the healthcare system to initiate alcohol withdrawal treatment as soon as mild withdrawal symptoms set in.