Alcohol, Tobacco and Other Drug Problems in Occupational Health Settings in India: Need for Primary Care Based Brief Intervention

Amit Chakrabarti, MDScientist “E” (Deputy Director – Medical)National Institute of Occupational Health

Indian Council of Medical ResearchGovernment of India

OutlineExtent of alcohol, tobacco and other drug

problems among occupational groups in India and its consequences

Need for primary care and community based screening, brief intervention and referral

Initiation of a primary care and community based trial among coal mine workers

Labor Sector in IndiaSize of labor sector in 2013China: 793 millionIndia: 481 millionUnited States: 158 million

Summary of Studies

Patterns & Consequences of Alcohol Misuse in IndiaNIMHANS, Bangalore; WHO; Government of India;

Collaborating centresObjective: Impact of alcohol misuse on health and socio-

economic wellbeing of users and their families and harms to persons in contact with users

Five regions: Cuttack – Odisha (sparse data on alcohol use, with poorer economic indicators); Dhule – Maharashtra (one of the most backward districts), Gangtok – Sikkim (large proportion of the population using traditional home brew / illicit alcohol), Surat – Gujarat (a state under long-time prohibition), Vishakapatnam – Andhra Pradesh (anecdotal reports suggested a high prevalence of alcohol use with rapidly changing economic parameters)

OutlineExtent of alcohol, tobacco and other drug

problems among occupational groups in India and its consequences

Need for primary care and community based screening, brief intervention and referral

Initiation of a primary care and community based trial among coal mine workers

NeedSocial cost for an alcohol dependent INR

30,000 / mo (Benegal et al, 2000) Expenditure on alcohol dependence by State

is much higher compared to excise revenue generated (INR 18 billion vs. 8.5 billion) (Benegal et al, 2000)

70% of economic cost of alcohol abuse can be attributed to loss in productivity (WHO, 2003)

Contd.Current addiction treatment facility

inadequate to provide treatment for dependents

Harmful users below the tip of the iceberg have to be provided intervention at the primary care and community level

Primary care and community based, cost-effective early detection, brief intervention and referral is the key

OutlineExtent of alcohol, tobacco and other drug

problems among occupational groups in India and its consequences

Need for primary care and community based screening, brief intervention and referral

Initiation of a primary care and community based trial among coal mine workers

PopulationCoal industry in India is one of the largest with a

turnover of INR 80,000 crore (US$ 13,000 million) and worker strength of approximately 3,60,000

However, regular consumption of tobacco and alcohol among workers in mining higher among occupational groups (almost 40%) increasing to almost 70% among workers with occupational injuries (Kunar et al., 2008)

In absolute terms, at least 1,10,000 workers in Indian coal mines are prone to adverse consequences of harmful substance use

ObjectivesASSIST and biomarker screening to identify

patterns of tobacco, alcohol and cannabis useBrief intervention as secondary prevention

among “hazardous and harmful” usersBrief intervention with add-on

pharmacological intervention among “dependent” users with alcohol as the main problem

Primary ScreeningHave you consumed alcohol, cannabis in any form

(eaten/beverage/smoked) and / or tobacco (smoked/smokeless) in any form during past one year?

Have you consumed alcohol, cannabis in any form (eaten/beverage/smoked) and / or tobacco (smoked/smokeless) in any form during the past 30 days?

Any worker responding “yes” to both questions for any or more than one substance recruited

Any worker responding “no” to any of the questions excluded

Allocation“Low-risk” for all substances provided general health advice &

excluded “Hazardous and harmful” participants randomly allocated:a) “Only screening” (ASSIST and biomarker screening and general

health advice) orb) “Screening and brief intervention (BI)” group (ASSIST and

biomarker screening and general health advice with add-on brief intervention).

“Dependent” users with alcohol as the main problem receive ASSIST and biomarker screening; general health advice; brief intervention along with add-on primary care based, supervised, randomized, double-blind:

c) Acamprosate two tablets of 333 mg (i.e., 666 mg) three times a day (i.e., 1,998 mg/d) for 3 months (12 weeks) or

d) Baclofen tablet of 20 mg three times a day (i.e., 60 mg/d) for 3 months (12 weeks)

ProceduresGENACIS (Gender, Alcohol and Culture: An

International Study) modified questionnaire with Harms to Others (H2O) (Wilsnack, 2009)

WHO Health and Work Performance Questionnaire (HPQ) (Kessler, 2003)

SF-36 questionnaire – Quality of life (Brazier et al., 1992)

Biomarker screening – EDTA whole blood PEth; and urinary cotinine and THC-COOH measured by ELISA

Health screening: Physical – All systems physical; Biochemical; Pulmonary function test (PFT)

Follow Up & Outcome MeasuresGeneral health advice and brief intervention on

recruitment; 3 and 6 monthsPharmacological intervention according to protocol

with follow ups at 3 and 6 monthsASSIST, Harms to Others (H2O), HPQ (Work

Performance domain only), SF-36, biomarker screening, health screening (physical, biochemical and PFT) after 3 and 6 months

Outcome measures will be ASSIST score; biomarker status; health status (physical, biochemical, PFT); absenteeism, injury, sickness, lost productivity, quality of life, harms to others

Preliminary ObservationsOut of n=21 with primary screening 90%

eligibleMean age 47.2±9.2 yearsAlmost 80% work 48 h or more64% do not perceive any work stressUser: Alcohol 90%, tobacco 81%, cannabis

19%ASSISTAlcohol: 10 = 14%; 26 = 44%; 27+ = 42%Tobacco: 3 = 19%; 26 = 76%; 27+ = 5%Cannabis: 3 = 25%; 26 = 75%

Contd.14% participants with ASSIST alcohol score

11 to 15 doing ok42% participants with ASSIST alcohol score

27+ actively seek medicationDrink size for unrecorded / non-commercial /

traditional or illicit alcoholFamily and health are key messages in BI;

also lifestyle modification as in other non-communicable diseases

Concluding CommentsATOD is a problem among occupational groups in

India; probably more than in general populationExisting addiction treatment facilities inadequateEarly brief intervention for high-risk harmful

user population has to be integrated at primary care and community

In the present study 6-month BI protocol per participant costs approximately INR 18,775 (US$ 310) vs. approximate economic cost of only harmful alcohol use INR 90,000 (US$ 1500) over 6 months (Gururaj, 2011)

Acknowledgement1. Vivek Benegal, MD; Professor of Psychiatry, Centre for Addiction

Medicine, NIMHANS, Bangalore2. Malay Ghosal, MD; Professor of Psychiatry, Medical College &

Hospital, Calcutta 3. Jayjit Mukherjee, MBBS, Medical Superintendent, Eastern Coalfields

Funding4. National Institute of Occupational Health, India5. Indian Council of Medical Research, New Delhi

Thank you!

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