|Year : 2013 | Volume
| Issue : 2 | Page : 120-126
Alcohol-related disorders among medical and surgical in-patients in a Nigerian teaching hospital
Olatunji A Abiodun1, Peter O Ajiboye1, Oluwabunmi N Buhari1, Kazeem A Ayanda2, Oluwatosin M Adefalu2, Lukman O Adegboye2
1 Department of Behavioural Sciences, University of Ilorin, Ilorin, Nigeria
2 Department of Behavioural Sciences, University of Ilorin Teaching Hospital, Ilorin, Nigeria
|Date of Web Publication||22-May-2013|
Peter O Ajiboye
Department of Behavioural Sciences, University of Ilorin, Ilorin, Kwara State, P.O. Box 825 GPO, Ilorin
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background/Objectives: Alcohol use disorders exist in a high proportion of hospitalized patients and this often complicates patient management, but a large proportion of them still go unrecognized by the managing clinicians. The objective was to provide data on the proportion of inpatients 18 years and above with alcohol-related disorders, and ability of the managing clinicians to detect these disorders.
Materials and Methods: Alcohol use disorders were assessed in 339 consecutive patients admitted into medical and surgical wards of University of Ilorin Teaching Hospital (UITH), Ilorin, using the Structured Clinical Interview for DSM-IV Disorders (SCID) -- Alcohol module, for a period of 5 months. They were also assessed for the presence or absence of alcohol-related problems (physical, psychological, and social) by direct questioning. In addition, patients' case notes were scrutinized for additional information on alcohol-related problems and ability of managing clinicians to detect alcohol-related problems in their patients.
Results: All patients with alcohol use disorders were males. The point prevalence for alcohol abuse and alcohol dependence using DSM-IV criteria were 16.4% and 8.5%, respectively among males while another 1.2% who did not meet DSM-IV criteria for abuse and dependence, had alcohol-related problems. Marital disharmony, financial problems, and deteriorating work performance were the most common psychosocial problems among the drinkers. Gastritis occurred in 18.5% of cases with alcohol abuse and 21.4% of cases with alcohol dependence. Other physical problems among drinkers included liver cirrhosis, malnutrition, and various injuries. Significantly more patients aged (45-64 years) and patients of low educational status compared to abstainers had alcohol use disorders and alcohol-related problems. In addition, significantly more patients with alcohol use disorders/alcohol-related problems compared to abstainers were observed to have physical and psychosocial health problems. Alcohol-related problems were detected in only 10.9% of the alcohol users by the managing clinicians.
Conclusion: There is a considerable case load of patients with alcohol-related disorders in the hospital. There is therefore the need to improve ability of the managing clinicians to detect and manage cases of alcohol-related disorders, with referrals where appropriate.
| Abstract in French|| |
Contexte/objectifs: La consommation d'alcool troubles existent dans une forte proportion de patients hospitalisés et ceci souvent complique la gestion des patients, mais une grande partie d'entre eux vont encore non reconnu par les gérant des cliniciens. L'objectif était de fournir des données sur la proportion de patients hospitalisés de 18 ans et plus souffrant de troubles liés à l'alcool et la capacité des cliniciens gérant pour détecter ces troubles.
Méthodes et matériaux: Alcool troubles liés ont été évaluées dans 339 patients consécutifs admis en quartiers médicaux et chirurgicaux de l'hôpital universitaire Université d'Ilorin (XOTE), Ilorin, à l'aide de l'entretien clinique structuré pour désordres de DSM-IV (SCID)-module de l'alcool, pour une période de 5 mois. Ils ont également été évaluées pour la présence ou l'absence de problèmes liés à l'alcool (physiques, psychologiques et sociales) par l'interrogatoire. En outre, les notes de cas de patients ont été examinés pour plus d'informations sur les problèmes liés à l'alcool et la capacité de gérer les cliniciens à détecter les problèmes liés à l'alcool dans leurs patients.
Résultats: Tous les patients atteints de troubles causés par l'utilisation étaient de sexe masculin. La prévalence ponctuelle pour l'abus d'alcool et de dépendance à l'alcool en utilisant les critères du DSM-IV étaient respectivement de 16,4 % et 8,5 % chez les hommes tout en un autre 1,2 % qui ne répondaient pas aux critères du DSM-IV d'abus et de dépendance, eu des problèmes liés à l'alcool. Mésentente conjugale, problèmes financiers et détérioration des performances de travail ont été les problèmes psychosociaux les plus courants parmi les buveurs. Gastrite s'est produite à 18,5 % des cas d'abus d'alcool et 21,4 % des cas avec l'alcoolo-dépendance. Autres problèmes physiques chez les buveurs incluent une cirrhose du foie, de malnutrition et de diverses blessures. Significativement plus élevé de patients âgés (45 - 64 ans) et les patients de faible niveau d'instruction par rapport aux abstinents eu alcool utilisent les troubles et les problèmes liés à l'alcool. En outre, beaucoup plus de patients ayant des problèmes alcool consommation liés à l'alcool/troubles par rapport aux abstinents ont été observés à avoir des problèmes de santé physique et psychosociale. Problèmes liés à l'alcool ont été détectés dans seulement 10,9 % des utilisateurs l'alcool par les gérant des cliniciens.
Conclusion: Il est une charge considérable de patients souffrant de troubles liés à l'alcool à l'hôpital. Il y a donc la nécessité d'améliorer la capacité des cliniciens gérant pour détecter et gérer les cas de troubles liés à l'alcool, accompagné des recommandations le cas échéant.
Mots clés: Alcool, troubles liés, patients hospitalisés, médecine, chirurgie
Keywords: Alcohol related, disorders, in-patients, medical, surgical
|How to cite this article:|
Abiodun OA, Ajiboye PO, Buhari ON, Ayanda KA, Adefalu OM, Adegboye LO. Alcohol-related disorders among medical and surgical in-patients in a Nigerian teaching hospital. Ann Afr Med 2013;12:120-6
|How to cite this URL:|
Abiodun OA, Ajiboye PO, Buhari ON, Ayanda KA, Adefalu OM, Adegboye LO. Alcohol-related disorders among medical and surgical in-patients in a Nigerian teaching hospital. Ann Afr Med [serial online] 2013 [cited 2020 Jul 15];12:120-6. Available from: http://www.annalsafrmed.org/text.asp?2013/12/2/120/112407
| Introduction|| |
Alcohol consumption has been shown to be causally related to over 60 different causes of morbidity and premature death worldwide.  Studies have also shown that even though alcohol-use disorders (AUDs) are more common in developed countries, lower but still substantial rates come from developing countries. ,, A Nigerian study found that there has been a rapid increase in alcohol availability and consumption in recent times and that common problems associated with excessive alcohol use are as abundant in Nigeria as they may be in other parts of the world. 
Despite the fact that alcohol use disorders exist in high proportion of hospitalized patients and that this often complicates patient management  , Aa large proportion of them still go unrecognized by the managing clinicians. The challenge for the clinicians is to learn enough about these disorders, and be able to identify them, since missing an AUD can complicate the assessment and treatment of other medical and psychiatric conditions.  In addition, preventing alcohol-related harm requires the accurate identification of individuals who misuse alcohol, and the implementation of evidence-based interventions to reduce alcohol consumption. 
Primary care, general hospital, and accident and emergency settings provide useful opportunity for screening for alcohol misuse and delivery of brief intervention.  In a study carried out among primary care patients in the middle belt region of Nigeria, Abiodun  reported that 50.1% of the patients were alcohol drinkers while 14.4% (21.4% among males and 5.8% among females) had one or more alcohol-related problems. All the cases of alcohol dependence (4.4%) reported in the study population were found to be males. Another study among primary care patients in Southern Nigeria,  found that 1.7% of the study population met the criteria for alcohol abuse and all identified cases were males.
Ahmed  in a review of patients with psychoactive substance use disorders admitted to the psychiatric department of a University Teaching Hospital in Northern Nigeria reported a 35% prevalence rate for alcohol abuse. Another study of psychiatric in- patients reported a rate of 19.9% of alcohol-related disorders in subjects treated for psychoactive substance disorders in 13 treatment centers in northern Nigeria. 
There are also some epidemiological studies on alcohol-related problems in Nigeria. In a study from the middle belt region of Nigeria (Jos), Obot  in a sample of 1562 respondents reported that 52.5% of the subjects described themselves as alcohol drinkers. In a more recent study, Gureje et al. in a sample of 6752 adults selected from 21 of the 36 states in Nigeria reported that alcohol was the most commonly used substance, with 56% ever users, and 14% recent (in the last 12 months) users. Also males were more likely than females to be users of every drug group investigated (alcohol inclusive).
While these epidemiological and hospital-based studies indicate the need to pay more attention to alcohol-related issues, available information have confirmed the dearth of data on in-patient alcohol studies in nonpsychiatric populations in Nigeria. Okulate et al. in a study done among medical and surgical in-patients in a military general hospital reported a prevalence rate of 49.1% for alcohol consumption and 14.8% for alcohol abuse. This is the only alcohol study among nonpsychiatric in-patients' population in Nigeria to the best of our knowledge. However, general hospital units especially those of tertiary health institutions provide opportunity for the study of a wide variety of medical and surgical health problems including any association these health problems may have with alcohol use. Such studies could provide preventive strategies for reducing health problems associated with alcohol use.
More studies on this important aspect of health problem are therefore necessary in order to improve upon the current dearth of available data on alcohol-related problems in tertiary health facilities in Nigeria.
The present study therefore aims to provide data on the proportion of in-patients, 18 years and above with alcohol-related disorders in a tertiary health institution in Nigeria and to also determine how many of these patients were detected by the managing clinicians as having alcohol-related problems.
| Materials and Methods|| |
University of Ilorin Teaching Hospital (UITH) is a 445-bed (19.3 beds per 100,000 population) tertiary health institution (owed by the federal Government) located in Ilorin, an urban center and capital of Kwara state of Nigeria, a country in the West Africa subregion. The hospital is the only tertiary health facility in the state, its primary catchment area, with a population of 2.3 million (2006 census).  Few referrals also come from neighboring states. Kwara state is located in the north-central or middle belt zone of Nigeria. There were a total of 96 beds in the medical wards (4.2 beds per 100,000 population) and 106 beds in the surgical wards (4.6 beds per 100,000 population) of the hospital at the time of the study. There was no trauma center in the hospital. At the time of the study, Kwara state also had five secondary care level general hospitals that were managed by general duty medical officers. These secondary care centers were largely poorly staffed and poorly equipped (owed by the state government) with low patient patronage unlike the federal Government owed University of Ilorin Teaching hospital (tertiary center) where most of the patients got referred to for treatment.
All consecutive patients aged 18 years and above admitted into the medical and surgical wards of the hospital during the study period (August-December, 2008), and who consented to participate in the study, constituted the study population. Each patient was assessed within 2-5 days after admission. The interview consisted of two stages. The first stage involved administration of questionnaire that covered the following areas: Socidemographic variables, past medical history, alcohol consumption (frequency of use and amount consumed in a typical week), and presence or absence of alcohol-related problems (physical, psychological and social). Subjects' occupation was classified according to the system of Boroffka and Olatawura  which is well operationalized and is comparable to other systems like the International Labour Organization classificatory system.  It has also been widely used in previous studies from this environment. ,,,,,,,, The categories are as follows: Group I consists of professionals with university degrees, e.g., doctors, lawyers, scientists, etc.; group II consists of professionals without university degrees and include teachers, administrators, large scale farmers, and armed forces officers; group III consists of clerks, motor vehicle drivers, mechanics, etc.; group IV consists of cooks, small scale farmers, barbers, etc.; group V includes laborers and petty traders; group VI includes full-time house wives, students, and unemployed educated youths (apprentices were included in this group). The questionnaires for this stage were administered by two trained research workers (Registrars in psychiatry). In line with SCID, current alcohol use was taken as alcohol use in the last 12 months, while alcohol use of over 12 months was taken as past alcohol use.
In addition to administering the questionnaires to the patients, their case notes were examined for additional information on alcohol-related problems, and also to determine if the managing clinicians documented the presence of alcohol-related problems in any portion of patients' case notes.
The second stage of the study involved assessment of all the patients for alcohol use disorders using the Structured Clinical Interview for DSM-IV Disorders (SCID) - Alcohol module. , Two trained research workers (senior Registrars in psychiatry) administered SCID to the patients. Agreement was good among the two raters for second-stage assessment (Kappa = 0.85).
Ethical approval to conduct the study was obtained from the hospital ethical committee.
Data were analyzed using the Statistical Package for Social Sciences, SPSS 15 for windows, and the level of statistical significance was set at 5%.
| Results|| |
Three hundred and forty nine patients were admitted during the study period but 10 patients were excluded because their ages were less than 18 years. All the eligible patients (339) participated in the study (100% response rate). The study population was made up of 174 (51.3%) females and 165 (48.7%) males who were admitted into the surgical and medical wards of the hospital during the study period. The mean age of the study population was 45.3 ± 17.9 years. Only males were identified to be involved with alcohol use during the study period. There were a total of 66 (40%) current alcohol users while 33 (20.0%) were past users. Primary (never used alcohol) abstainers constituted 40% (N = 66) of the study population. Out of the 66 current alcohol users, 27 (16.4%) and 14 (8.5%) met the DSM- IV criteria for alcohol abuse and alcohol dependence respectively. Since all the identified cases were males, this gives a point prevalence of16.4% and 8.5% for alcohol abuse and dependence respectively [Table 1].
|Table 1: Alcohol use disorders and alcohol related (physical and psychosocial) problems among medical and surgical male inpatients in a Nigerian teaching hospital|
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[Table 2] shows the comparison of male patients with AUD and alcohol-related problems (ARP) with abstainers on sociodemographic characteristics.
|Table 2: Comparison of male patients with alcohol use disorders/alcohol-related problems with abstainers on demographic characteristics|
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Significantly more middle-aged males (45-64 years) (χ2 = 18.062; df = 2; P < 0.001) had AUD or ARP compared to abstainers. Significantly more people with low educational status (primary school education) had AUD or ARP compared to abstainers (χ2 = 27.627; df = 3; P < 0.001).
Alcohol-related physical and psychosocial problems were recorded 40 times in the study population. This is made up of all the 14 patients with alcohol dependence, where the problems were recorded 19 times (some individuals had more than one problem), 17 of the 27 patients with alcohol abuse and 2 of the 25 current alcohol users with no diagnosis of AUD. Thus, a total of 33 current drinkers (20.0% of male study population) had ARP. In addition, 2 out of 33 past alcohol users (1.2% of male study population) were found to have alcohol-related physical health problems (liver cirrhosis). The distribution of ARP (physical and psychosocial problems) among the drinkers who had specific DSM- IV diagnosis and those without any diagnosis are as follows: Gastritis occurred in 18.5% of the 27 drinkers who had alcohol abuse and 21.4% of 14 drinkers with alcohol dependence. Marital disharmony, financial problems, and deteriorating work performance were the most common psychosocial problems. Marital disharmony occurred in 3.7% of 27 drinkers with alcohol abuse disorder, and 21.4% of 14 drinkers with alcohol dependence while financial problems occurred in 3.7% of patients with alcohol abuse disorder and 21.4% of patients with alcohol dependence. Also 7.4% of the 27 patients with alcohol abuse and 14.3% of the patients with alcohol dependence had deteriorating work performance.
Twenty five (37.9%) of the 66 current alcohol users did not have any specific DSM- IV diagnosis of AUD, but 1 (4%) of them had liver cirrhosis and another 1 (4%) had anemia resulting from malnutrition.
There were significantly more physical health problems (e.g., gastritis, liver cirrhosis peripheral neuropathy, malnutrition, injuries) in patients with AUD/ARP compared to abstainers (χ² with Yate's correction = 57.47; df = 1; P < 0.001). Similarly, psychosocial health problems (e.g., marital disharmony, financial problems, child neglect, deteriorating work performance) occurred significantly more among patients with AUD/ARD compared to abstainers (χ² with Yate's correction = 31.64; df = 1; P < 0.001).
It was found that ARP was documented in the case notes in only 10.9% of cases by the managing clinicians.
| Discussion|| |
This study reported a prevalence of 16.4% and 8.5% for alcohol abuse and dependence, respectively. This finding is similar to reported findings which range between 10% and 14.8% in developing countries , and between 7.4% and 18.3% in developed countries. ,,, It is however higher than that of Coder et al.  another study from a developed country, which reported a prevalence of 5.3% for AUD. Methodological differences, using a population that is at risk for problem drinking and using a short study period such as a single day, 14 days or a month are some of the reasons reported to be responsible for overestimation of the proportions of AUDs in general hospital studies.  In this study the reported prevalence could be said to be modest based on the methodology and duration of the study (5 months).
The pattern of alcohol-related physical and psychosocial problems identified in the present study was also found to be quite comparable to findings from developed ,,,,,,, and few available ones from developing countries. , Psychosocial problems reported from developed countries include marital problem, increase severity of psychiatric symptom, decrease level of social, and occupational functioning but the two studies from developing countries did not report any psychosocial problem. Furthermore, the observation from this study that significantly more physical and psychosocial health problems occurred among patients with AUD/ARD compared to abstainers would support an etiological role for alcohol for these health problems.
It was also observed in this study that only males were identified to be alcohol users even though more than half of the study population was female. The absence of female alcohol users within the study population may be related to religious and cultural factors in the study area. Nigerian women are culturally likely not to drink alcohol nor smoke cigarettes. Culture thus serves as a very important protective factor for Nigerian women against alcohol-related problems. These cultural factors are thus responsible for the observation that generally in developing countries alcohol use, abuse, and dependence occur predominantly among the male population. ,,,
It was found from this study that significantly more middle-aged (45-64 years) and more people with lower educational status had AUD and ARP compared to abstainers. These findings are similar to results obtained in studies from both developed and developing countries , but differ from other studies from similar settings in the developed countries that reported AUD to be significantly more in younger people of lower socioeconomic status, unmarried, divorced men or divorced, and cohabiting females. ,,
It was also observed that ARP occurred in 21 (12.7%) of the patients with alcohol abuse. Alcohol-related problems were recorded 19 times (11.5%) in all the14 patients with alcohol dependence (some had more than one problem), and in 2 (1.2%) of the 25 patients who did not have specific DSM-IV diagnosis of AUDs. Also, the distribution of physical problems among these drinking patients that did not have specific DSM-IV diagnosis of AUDs included liver cirrhosis (0.6%) and anemia resulting from malnutrition (0.6%). This latter finding indicates that a small but significant proportion of patients with ARP could be missed if efforts are limited to only DSM-IV AUDs or ICD- 10 categories of alcohol dependence and harmful use. In more recent years, increased attention globally has been focused on the prevention and early management of alcohol-related problems. In order to fully achieve this, there is therefore the need to look beyond the frame of alcohol abuse/dependence which had tended to dominate the concerns of alcohol-related research over the past decades. 
This study also observed that only 10.9% of patients having ARP were identified by the managing clinicians. Reported identification rates from developed countries ranged between 7% and 89% depending on whether it was based on just a specialty or the entire hospital. ,,,, Studies in developing countries have reported that health workers do not normally detect ARP in patients under their care ,, The 10.9% reported in the current study is still an indication that clinicians need to improve on their ability to detect ARP in their patients. However a limitation of the present study is the use of rate of documentation of ARP by the managing clinicians to be synonymous with rate of detection. This may not always be so since ARP detected by the managing clinicians may not be documented. However, where ARP is detected but not documented, the patient is less likely to benefit from any therapeutic intervention. Finally, clinicians need to take up the challenge to learn more about alcohol-related disorders since missing alcohol use disorders can complicate the assessment and treatment of other medical problems.  There is therefore a role for consistent screening for AUD in hospitalized patients, provision of education about screening, institution of brief intervention techniques, and referral for treatment where appropriate. 
| Conclusion|| |
There is a considerable load of patients with alcohol-related disorders in the hospital studied and many of these cases were not detected by the managing clinicians. There is therefore an urgent need to improve the ability of managing clinicians to detect cases of ARP. The clinicians also need to be trained on how to manage cases detected with appropriate referrals where indicated. Collaborative work between psychiatrists, and nonpsychiatric health personnel (e.g., through seminars, workshops, consultation- liaison services, etc.) would be required to achieve this.
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[Table 1], [Table 2]