Alcohol in Russia: Selected Medical and Social Aspects

INTRODUCTION

The problem of excessive alcohol consumption in the Russian Federation (RF) is well known; but there is a tendency to exaggerate it, which is evident for inside observers. The exaggeration aims at disguising shortcomings of the healthcare, with responsibility for the relatively high mortality, especially in males shifted onto people as if it were self-inflicted by alcohol. Heavy drinking is a criminogenic factor; but again, the alcohol-related crime tends to be exaggerated by Russian media. In this way, organized crime and corruption are obfuscated. Furthermore, alcohol is often mentioned by the literature and media in the context of family violence and child abuse. Without denying the problem, it should be commented that it is easier to incriminate a socially unprotected offender, in particular, an alcoholic. Otherwise, various tools are applied to prevent a disclosure: denial of facts, allegations of slander, threats, and provocations, and appeals to preserve the honor of the family; more details and references are in the preceding papers.^1,2

RECENT HISTORY

During the anti-alcohol campaign (AAC), launched by Mikhail Gorbachev in 1985 and ended with failure by 1988–1989, the consumption of non-beverage alcohol was widespread: lotions and technical fluids such as window-cleaner. Large-scale sales of cheap eau de cologne and window cleaner in some areas were tolerated by authorities. The drinking of alcohol-containing technical liquids and perfumery decreased abruptly after the AAC, when vodka, beer, and other beverages became easily available and relatively cheap. Alcohol consumption predictably increased after the AAC. It facilitated economic reforms of the early 1990s: workers did not oppose the privatization of factories due to mass drunkenness. Following the abolition of the state alcohol monopoly in 1992, the country was flooded by alcoholic beverages of poor quality, sold through legally operating shops and kiosks. During the 1990s, ethanol was massively transported to Russia from Georgia; the author observed a long line of tank trucks queuing at the border. It was used for the production of vodka and other beverages including wine and beer. North Ossetia has been known as a nationwide source of cheap alcohol. Beverages sold in Russia with special reference to quality and toxicity have been reviewed previously. ^1,2

Legally sold alcoholic beverages sometimes cause poisonings up to lethal ones. The incidence of fatal intoxications increased in the early 1990s. The following absolute figures for lethal poisonings with alcohol-containing fluids were reported: 1998 – 21,800, 1999 – 24,100, and 2000 – 27,200.³ In 2006, a mass poisoning with jaundice was supposedly caused by the disinfectant Extrasept-1 sold in vodka bottles in different regions of Russia. Reportedly, Extrasept-1 contained “0.08–0.15% or, on average, 0.45 mg/mL” of diethyl phthalate and “0.1–0.14% or, on average, 0.344 mg/mL” of polyhexamethylene guanidine hydrochloride (PHMG).⁴ Other authors reported that respective concentrations of 0.08–0.15% and 0.1–0.14% were also found. The number of poisonings during the period August–November 2006 was 12,611 cases, among them 1189 lethal ones;^5,6 factual figures were probably higher. Histologically, “cholestatic hepatitis with a severe inflammatory component” was described.⁶ However, PHMG is not particularly hepatotoxic; it is used worldwide for disinfection of swimming pools. Apart from PHMG, “chloride compounds” have been discussed as possible causative factors.⁷ There is a hypothesis that carbon tetrachloride, dichloroethane, or other organochlorides, used for the dry cleaning of clothes, caused the mass poisoning.^8,9 The median lethal dose (LD₅₀) for PHMG is 500–800 mg/kg in rats and rabbits,^4,10 which, extrapolated to humans, indicates that a person weighing 100 kg would have to ingest ~60 kg of Extrasept-1 to receive LD₅₀ of PHMG. Moreover, the animals died with neurological symptoms, not from hepatotoxicity. As for diethyl phthalate, its acute toxicity to mammals is low; details and references are included.¹¹

Illegally produced cheap vodka containing technical alcohol was sold through shops and eateries.¹² Poor-quality alcohol has been added to beer and wine. Consumers smelled it; the astringent taste of technical ethanol is known as it has been purloined from factories and scientific institutions, being often used for drinking during AAC. This has been veiled by some writers creating the impression that consumers deliberately bought disinfectants for drinking: “This outbreak was caused by the consumption of antiseptics with chloride compounds due to the deficit of other non-beverage alcohol.”⁷ There was not a “deficit of other non-beverage alcohol” but a temporary deficit of vodka caused by the elevation of excise duties.³ The shortage was compensated by surrogates sold in vodka bottles.⁵ Furthermore, 77 lethal cases were reported from Irkutsk in 2016. According to published information, the poisoning was caused by the bath lotion Boyaryshnik (Hawthorn) containing methyl alcohol.^13,14 However, it is suspected that the poisoning was caused by the medicinal hawthorn (Crataegus) tincture, which is the pharmacy product most frequently consumed by drinkers in Russia.¹⁵ The misinformation was probably intended to disguise the fact that methanol was used as a cheap substitute for medicinal ethanol.

Exaggeration by some writers of “unrecorded” alcohol consumption is shifting responsibility for poisonings onto consumers, who supposedly prefer drinking surrogates.¹⁶ The concept of unrecorded alcohol is not directly applicable to Russia without a comment that ethanol from non-edible sources, diverted from the industry or imported, has been used for the production of beverages sold through legal shops,^12,17-20 thus being formally recorded. This occurred generally with the knowledge of authorities. Most vodka and liquor consumed by the population is purchased in legally functioning retail stores.²¹ The Internet trade has been typically for bulk orders only.²² Without opening the bottle, consumers are usually unable to distinguish between branded and falsified vodka as it is sold at the same shops and looks identical. In the 1990s, slanting labels and lax closures were known as attributes of falsified vodka. Today, bottles with counterfeit beverages are “in good accordance with the original products.”²² The quality of alcoholic beverages was improving after the mass poisonings discussed above; but in the third year of the Ukraine war (2024), beer and vodka seemed to smell poor-quality alcohol more often.

According to the official statistics, the adult per capita consumption of recorded vodka and other spirits was declining in RF with some fluctuations from 1998 to 2013.²³ As per the Global Information System on Alcohol and Health, both the total (since approximately 2005) and recorded (the data are available from 2010 to 2019) alcohol consumption is gradually declining.²⁴ The worldwide sharpest decreases in per capita consumption were recorded in Russia (from 18.7 L in 2005 to 11.7 in 2016) and some other countries of the former SU. The number of alcohol psychosis cases in RF dropped over the period 2007–2016 from 52.3 to 20.5/100,000 population.²⁵ The mortality from the toxic effects of alcohol decreased from 13.3 to 6.7 cases/100,000 over the period 2010–2019. Heavy binge drinking is visibly in decline. Unlike in the 20^th century, it is difficult to meet a heavily drunk person today even among marginalized people. The drinking of vodka and fortified wine has been partly replaced by beer. As for young people, many of them adopt a moderate alcohol consumption style from the beginning.

In the author’s opinion, the cause of the decline in heavy binge drinking and overall alcohol consumption is (1) unpredictable and often poor quality of legally sold beverages and (2) responsible way of life under the conditions of the market economy. The latter pertains to the social strata that included the majority of alcohol consumers, that is, industrial workers, and intelligentsia. Although workers were often skeptical about Soviet ideology, they were influenced by propaganda about the supremacy of the working class and were confident about their future. This confidence has been lost during the economic reforms of the 1990s. Many factories were closed and the workers faced unemployment in an inadequate social security system. The same fate awaited intelligentsia, as many scientific institutions were closed or their personnel reduced. At the same time, property-related crime against people with alcohol use disorders has become widespread. Such ambiance does not predispose to leisure drinking. Many alcoholics have lost their residences and become homeless. The economic situation is improving but the Soviet-time drinking habits are not coming back. Furthermore, ethnic Russian workers have been gradually replaced by immigrants from Central Asia and the Caucasus, where alcohol consumption is less widespread.²⁶ The changes are less conspicuous in some smaller towns and rural areas, but in places, there have been tensions due to immigration from regions where less alcohol is consumed, such as the North Caucasus.

ANTI-ALCOHOL POLICIES

The impact of recent “alcohol control policy measures”²¹ on mortality has been discussed in some Russian literature as if alcohol was the single most important agent determining the death rate. Other factors have not been taken into account, in particular, the availability and adequacy of healthcare and enhanced toxicity of some legally sold alcoholic beverages. Certain writers have exaggerated the efficiency of governmental policies.^21,23 The following citations are illustrative: “The effect of alcohol taxation measures is likely to be significant and moderately positive. However, its significance was outperformed with much stronger effects of the measures to reduce availability of ethyl alcohol and non-beverage alcohol with very high alcohol content;” and “All these measures greatly reduced the amount of ethyl alcohol available.”²¹ Vodka, beer, and other beverages have been easily available since the AAC: sold in supermarkets and other shops; with no queues like in the Soviet times. The average salary/vodka price ratio remained several times higher than it had been before the AAC. In their Russian-language book, Khaltourina and Korotayev discussed the role of the “crisis of medicine,” denying any significant role of this factor in the mortality elevation.²⁷ Their argumentation is unconvincing, for example, the unchanged since the Soviet time mortality from stroke despite its increased incidence. The overdiagnosis of cardio- and cerebrovascular diseases in unclear cases, both at autopsies and in people dying at home, has been discussed above and in the preceding paper.²⁸ The registered cardiovascular mortality elevation after 1990 reflected, in fact, the quality decline of postmortem diagnostics. The decrease in infant and maternal mortality since 1999, proposed as evidence of healthcare improvement,²⁷ may reflect priorities in the policies but is unrelated to the higher mortality of middle-aged and older men,²⁹ who are visibly underrepresented among patients in governmental policlinics. There is also mistrust toward medicine due to its commercialization and uneven quality. For these and other reasons, many people stay at home even if they have symptoms, receiving no adequate therapy for chronic diseases.

As discussed above, consumption of technical liquids and perfumery decreased abruptly after AAC so the “non-beverage alcohol with very high alcohol content” ²¹ has hardly played any significant role as a cause of enhanced mortality after AAC. Illegally manufactured beverages, both by regular factories evading taxation and by non-industrial producers (so-called garage vodka), have been sold through legally operating retail,¹² generally with the knowledge of authorities. The “specific alcohol control policy measures” ²¹ have been rather superficial, resulting in moderate oscillations of the vodka price considering inflation, and no real decrease in availability since the AAC. Some governmental measures may have even contributed to the consumption of higher doses, for example, the disappearance of small (0.33l) beer cans and the rareness of 150–200 mL vodka vials. The prohibition of alcohol sales between 11 p.m. and 8 a.m. since 2011 (beer since 2013) resulted in purchasing by some people larger amounts in advance with subsequent consumption. Physical restrictions on alcohol availability may cause some decrease in total consumption but contribute to occasionally heavier binge drinking. In this way queues at retail outlets during the Soviet period: after queuing, larger amounts of alcohol were purchased and then consumed. Analogously, having waited in a queue at the entrance to a beerhouse (pivnoi bar), visitors usually stayed there for hours. This was a foreseeable consequence of the anti-alcohol measures restricting alcohol sales and maintaining queues during the Soviet period.

ALCOHOL-RELATED MORBIDITY AND MORTALITY

After AAC, the average life expectancy in Russia decreased especially in men; in the period 1993–2001, it was estimated around 58–59 years.^19,30 Admittedly, the life expectancy has been increasing since approximately 2004. Among the causes of enhanced mortality have been the limited availability of modern health care, late detection of malignancies,³¹ poor quality of legally sold alcoholic beverages (i.e., substances other than ethanol), offenses, and crime against alcohol-dependent people resulting in homelessness and premature death.

The cause of the high registered cardiovascular mortality in the former Soviet Union (SU), and its further increase after 1990, is evident for anatomic pathologists. There is a tendency to overdiagnose heart diseases both at autopsies and in people dying at home, not undergoing postmortem examination. If the cause of death is not entirely clear, a standard postmortem diagnosis is “Ischemic heart disease with cardiac insufficiency” or alike.²⁸ Not surprisingly, the deterioration of quality in pathology and other healthcare services during the 1990s coincided with an elevation of the registered cardiovascular mortality.³² This could be indirectly confirmed by the following citation: “Increases and decreases in mortality related to cardiovascular diseases; but not to myocardial infarction, the proportion of which in Russian cardiovascular mortality is extremely low.”³⁰ Indeed, the diagnosis of myocardial infarction is usually based on distinct clinical or morphological criteria, while ischemic or atherosclerotic heart disease with cardiac insufficiency is often used post-mortem without strong evidence. Furthermore, the overdiagnosis of heart diseases is compatible with the “absence of any substantial variation in mortality rates from neoplasms, including those related to alcohol, during the period 1984-1994”³³ because cancer is rarely diagnosed without evidence. Remarkably, the mortality from lung cancer (requiring X-ray or autopsy for the diagnosis) in males decreased by 17% over the period 1998–2007, while that from breast cancer, rarely remaining undiagnosed, “increased considerably.”³⁰ Finally, the irregular treatment of arterial hypertension^34,35 and diabetes mellitus contributes to cardio- and cerebrovascular mortality.

Another citation to be commented: “The changes in Russian mortality in the past few decades are unprecedented in a modern industrialized country in peacetime.”³⁶ Indeed, between 1984 and 1994, mortality rates in Russia underwent a rapid decline followed by a steep increase. The magnitude of the fluctuations raised questions about the validity of reported mortality figures. An artifact was among the causes of the “huge variation in Russian mortality.”³³ The mortality decrease after 1985 could have been initially overstated to highlight the successes of AAC, which has been subsequently compensated by overstated mortality figures. Manipulations with statistics have been not unusual in the former SU.³⁶

Certain Russian authors exaggerate the cause-effect relationships between alcohol and cardiovascular mortality, depicting the high mortality as largely self-inflicted by alcohol.³⁷ This tendency is relatively new. An epidemiological study from the 1970s reported that the prevalence of cardiovascular diseases including hypertension was not significantly different among men who drank excessively compared to the general male population.³⁸ Furthermore, heavy binge drinking was discussed as a cause of the increased mortality in RF. Without denying the harm from this hazardous pattern of alcohol consumption, it should be noted that heavy binge drinking tends to decline in Russia.^23,24

TREATMENT OF ALCOHOLICS: SELECTED ASPECTS

This section is an updated excerpt from the recent article; more references can be found here³⁹ and in the book.³¹ Intravenous detoxification was recommended for hospitalized patients with alcohol-related disorders including moderately severe withdrawal syndrome: 7–10 infusions daily, sometimes combined with intramuscular injections. Intravenous infusions have been regarded to be indicated in nearly all alcohol-depended patients. Recommendations of intravenous infusion therapy for alcohol intoxication and withdrawal syndrome with both crystalloid and colloid solutions were found also in recent instructive publications. Many cases with symptoms of excessive infusions, fluid overload, pulmonary, or generalized edema have been reported. In particular, certain dextran solutions (polyglucin and rheopolyglucin) were broadly used in Russia before adverse effects have been more fully understood.^40,41 Some methods were proposed, for example, infusion therapy and transcerebral electrophoresis of magnesium as a treatment for alcohol withdrawal syndrome. According to the Cochrane review, there is no sufficient evidence to decide whether or not magnesium is useful for the therapy of alcohol withdrawal syndrome.⁴² Excessive intravenous supply of magnesium can cause adverse effects. Fatal overdoses of magnesium in alcohol consumers were recorded. Besides, various intramuscular injections were recommended: magnesium sulfate, sodium bromide and thiosulfate, subcutaneous infusions of saline, and insufflations of oxygen; unithiol, dimercaprol, craniocerebral hypothermia; extracorporeal ultraviolet irradiation of blood, sorbent hemo- and lymphoperfusion, etc.^31,39

The recommended duration of the intravenous detoxification was 5–12 days, or even 14–25 days according to some instructions; a more recent publication recommended 2–3 days. This is generally at variance with the international practice. The differential diagnosis between hangover and alcohol withdrawal syndrome is of particular importance for the former SU, where both conditions have not been clearly distinguished in some textbooks and instructions. Alcohol and its metabolites are eliminated spontaneously while rehydration can be usually achieved per os. Long-lasting drip infusions are uncomfortable. It is known that the attitude toward patients supposed to have an alcohol use disorder has been less responsible with lower procedural quality assurance. Repeated infusions, and endovascular, and endoscopic manipulations lead to transmission of viral hepatitis, which is unfavorable especially if combined with alcohol-related liver damage.^31,39

Furthermore, antipsychotic drugs (phenothiazines and haloperidol) have been applied in adults and adolescents diagnosed with alcohol dependence in the absence of psychosis. The alcohol craving has been interpreted as an altered state of consciousness, as a delusional phenomenon within the scope of “productive psychopathology.”⁴³ The anti-psychotic medication has been recommended by widely used handbooks. Apart from other side effects, the synergism between some antipsychotics and ethanol, possibly aggravating liver injury, should be taken into account. Regarding alcohol-related dementia (and other dementia in alcohol consumers), it should be stressed that the use of antipsychotic drugs is associated with increased risks of stroke, venous thromboembolism, myocardial infarction, heart failure, pneumonia, and acute kidney injury.⁴⁴ Unfounded psychopathological interpretations of alcohol consumption and overextended diagnostic criteria of alcoholism have been pointed out.^31,39 In fact, many individuals classified as alcohol-dependent are socially adapted and well-functioning. Not all alcohol consumers become dependent and not all dependent people progress to unfavorable outcomes.⁴⁵

Among patients with alcoholism, biopsies were taken from kidneys, pancreas, liver, lung, salivary glands, stomach, and skin also for research, repeatedly in some cases. It was concluded based on a series of biopsy studies that a generalized cytoskeleton abnormality with an accumulation of filaments of intermediate type in macrophages, epithelial, and other cells is typical for cell damage by ethanol.^46-49 It is known that Mallory bodies, seen in alcoholic hepatitis and some other liver conditions, contain filaments of intermediate type; but generalizations as cited above have never been confirmed by other researchers. In any case, the cytoskeleton can be studied in experiments or post-mortem. Another example: renal biopsies were collected from patients with chronic alcoholism and nephritic symptoms, whereas “intracapillary proliferative glomerulonephritis” was diagnosed in all cases. In a later study by the same researchers, the histopathological findings in 40 of 43 patients with alcoholism and nephritic symptoms were morphologically classified as mesangiocapillary Gn; while in 29 of 31 patients with nephritic symptoms without alcoholism, “fibroplastic” Gn was diagnosed.^50,51 The striking difference between the two groups is difficult to explain. Other invasive procedures (celiacography and endoscopic cholangiopancreatography) were applied in persons diagnosed with alcohol use disorder without clear indications.⁴⁶

People with alcohol use disorders are at risk for invasive procedures without sufficient clinical indications. Some of such methods have been discussed previously.^52-54 For example, according to official instructions, the surgical treatment of tuberculosis in alcoholics should be started earlier, that is, after a shorter period of medical therapy. Mikhail Perelman insisted on early surgery in tuberculosis patients with alcohol dependence and operated on them also in the absence of demonstrable Mycobacterium tuberculosis. At the same time, he noticed that alcoholics have more frequent post-surgery complications.⁵⁵

DISCUSSION

The problem of excessive alcohol consumption in Russia is well known; but there is a tendency to exaggerate it, which is evident for inside observers. The exaggeration aims at disguising shortcomings of the healthcare, with responsibility for the relatively short life expectancy, especially among males shifted onto the people, that is, self-inflicted diseases caused by excessive alcohol consumption. Alcohol abuse is a known criminogenic factor; but again, alcohol-related delinquency is sometimes exaggerated by Russian literature and media to veil the non-alcohol-related organized crime and corruption. When discussing family violence and child abuse, both professional literature and the media often overemphasize alcohol abuse. Without denying the problem, it should be commented that it is easier to denounce a socially unprotected perpetrator, in particular, an alcoholic. Otherwise, various tools are applied to prevent a disclosure: denial of facts, allegations of fantasies or mental abnormality in the victim, threats and intimidation, and appeals to preserve the honor of the family or nation. About 99% of publications on outcome evaluation of child maltreatment were based on the research conducted in more developed countries, around 83% in the United States;⁵⁶ while in less open societies, family violence persists without much attention. According to an estimate, the prevalence of family violence in the Russia during last decades has been 45– 70 times higher than, for example, in the United Kingdom and France.⁵⁷

Exaggeration by some authors of the “unrecorded” alcohol consumption shifts responsibility for poisonings onto consumers, who allegedly prefer drinking surrogates.¹⁶ The concept of unrecorded alcohol is not directly applicable to Russia without a comment that ethanol from non-edible sources, diverted from the industry or imported, has been used for the production of beverages sold through legally operating shops and eateries,^12,17-20 thus being formally recorded. This occurred generally with the knowledge of authorities. In fact, most vodka and liquor consumed by the population has been purchased in legal retail stores.²¹

Certain Russian authors exaggerate the cause-effect relationships between alcohol and cardiovascular morbidity/mortality,³⁷ thus depicting the increased death rate as partly self-inflicted by alcohol. This tendency is relatively new. An epidemiological study from 1977 reported that the prevalence of cardiovascular diseases including hypertension was not significantly higher among men who drank excessively than in the general male population.³⁸ Furthermore, heavy binge drinking was discussed as a determinant of the increased mortality in Russia.⁵⁸ Without denying the harm from this hazardous pattern of alcohol consumption, it should be noted that heavy binge drinking is visibly declining in Russia.

Labor productivity is growing, but unemployment is persisting, and there are not enough prestigious jobs for everybody. Following the example of more developed countries, aged alcohol-consuming people should be given the possibility to spend their time in public houses and then go home, under the condition of maintenance of public order. It might be an idea to reintroduce inexpensive Soviet-time beer halls with the only difference: there must be enough places to sit. Visitors in low-cost beer halls during the Soviet era had to stand, which was a hardship for aged workers after the end of the work day. Moderate alcohol consumption should be permitted in homes for the aged. Today, conditions in Russian facilities lag behind their Western counterparts, with some personnel being bossy and not always friendly to the residents. Certain for-profit homes for the aged leave the decision on the beer-drinking permission to pay relatives, which is a human rights violation and humiliation. It should be taken into account that alcohol is contraindicated in certain diseases, and incompatible with some drugs, which necessitates competent advice. Experience of foreign countries must be studied and foreign advisors invited. At the same time, clinical attachment of Russian doctors abroad should be encouraged. More international trust is needed for that. Improvements in professional skills and remuneration of employees at the homes for the aged and psychiatric hospitals are necessary, while human rights in such facilities should not be ignored. According to the principles of medical and common ethics, society must care for its unprotected members, including aged persons suffering from alcohol use disorders.

The government must care about weaker members of society, including those suffering from alcohol-related dementia because they can be abused in their families or expropriated by criminals. It should also be recommended that Russian authorities investigate the cases when alcoholics, disabled and other people were deprived of their apartments or houses as a result of criminal acts or fraud, having become homeless, and to help these people to obtain decent accommodation. For prevention, detection strategies such as whistle-blowing schemes should be maintained.

CONCLUSION

After all, the conclusion is cautiously optimistic: heavy binge drinking and overall alcohol consumption are declining in Russia. However, there is still a need to prevent offenses against people with alcoholism and alcohol-related dementia, aimed at the appropriation of their residences, other properly, to improve healthcare and public assistance. Unfortunately, it is hard to disagree that alcoholics in Russia have sometimes been those who can be disdained, rejected, hated and persecuted, legally and without a sense of guilt.