Drink-drive offender seeks help for alcoholism
Dr Tanvir Jamil discusses
Dr Tanvir Jamil discusses
Ray is a 40-year-old mechanic who has had a long history of alcoholism. He and his wife have made an appointment to see you as he has just lost his licence after being found guilty of drink-driving. He tells you he is drinking a couple of cans each night.
I know the maximum recommended weekly alcohol intake for men is 21 units and for women it is 14.
The recommendations are now based on daily intake rather than weekly. For men it is no more than three units per day; for women, no more than two. This change may help guide your patients who do not drink for a whole week, then binge their entire 21 or 14 units on a Saturday night.
The unit measure is also rather inexact. Some beers and lagers can have twice or three times the amount of alcohol as others (see below).The best way to calculate the number of units consumed is to use the formula alcohol by volume (%) x volume in litres. So a can of strong lager will have: 9 x 0.5 = 4.5 units per can! So someone drinking one can of this is already over the recommended intake.
Is there any point in doing anything more than listen to Ray? I have heard some studies show nothing works better than telling an alcoholic to 'stop drinking because it's bad for you'.
That may be true – however, there is a lot we can do as GPs to help support and guide these patients and their families when they do want to stop drinking. Many alcoholics go through life losing everything they have – their driving licence, their job, their marriage, their children, their house... Some may just stop after being advised by their GP, spouse or friend to give up. Others drink until the bitter end.
We as GPs need to be vigilant. All indicators are that alcoholism is increasing – in women, in the elderly (almost 12 per cent of men and 6 per cent of women over 65 are problem drinkers), and in men under 25. Alcohol affects heart disease, hypertension, cancer, road accidents and pregnancy, causing almost 30,000 excessive deaths per year in the UK.
Apart from number of units consumed, how do you detect at-risk patients?
Drinkers can be classified into four groups:
- social drinkers – keep to recommended limits; unlikely to become damaged
- at-risk drinkers – drink over the limit; potential for harm
- problem drinkers – damage is occurring
- physically dependent
Men who drink more than 50 units a week and women who drink more than 36 units a week are at definite risk of harm. Generally, the higher the intake the greater the harm, but this is not a linear relationship. Some manage to survive quite well through a lifetime of drinking whereas others do themselves harm at much lower levels.
In a typical GP's list of 2,000 patients, there will be seven 'physically dependent' drinkers (half will be known) and almost 40 problem drinkers (of whom only a fifth will be known).
Asking your patients how much they drink is a good start for assessing risk. Another method is the CAGE questionnaire.
- Have you ever felt you should CUT down your drinking?
- Have people ANNOYED you by criticising your drinking?
- Have you ever felt bad or GUILTY about your drinking?
- Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (EYE-opener)?
Alcohol dependence is likely if the patient gives two or more positive answers.
You could also ask the patient to keep a drink diary. On each day they record:
- the amount of alcohol consumed
- the circumstances
- how they felt before and after
- the consequences
Certain presentations are suspicious:
- physical – GI symptoms, fits, faints, jaundice, trauma, withdrawal symptoms, smelling of alcohol, 'beer belly'
- psychological – depression, anxiety, drug abuse
- social – financial problems, legal problems (such as crime, driving offences)
- family history – domestic violence, psychological problems in spouse and children
So what can I do for Ray?
Ray is typical of the way most alcoholics are detected in general practice – they present after a crisis related to alcohol. Other typical presentations include a history from a worried relative and detection of alcohol-related damage during routine screening. Very few NHS hospitals now do in-patient detox and the vast majority is home detox co-ordinated by GPs or specialist addiction centres.
Home detox is also more successful and safer if the patient has a supportive family. You can also recommend joining the local Alcoholics Anonymous (AA) for the patients, Al-Anon for the spouse and Al-Ateen for children of alcoholics. At the end of the day, however, Ray must have the motivation.
What is a good detox regime?
A reducing dose of chlordiazepoxide is the treatment of choice (see table right). It has a relatively long half-life and is less likely to be abused than diazepam. You may need to alter the dose depending on symptoms, weight and sex. Ideally, you should see the patient daily to encourage him to continue and detect any problems.
Consider also haloperidol (for any psychotic problems, eg hallucinations or delusions) and oral thiamine and vitamins B and C. Involve district nurses, community psychiatric nurses, consider antabuse or acamprosate to prevent relapse and regular blood tests (MCV, GGT, ALT, AST).
Tanvir Jamil is a GP in Burnham, Buckinghamshire
- Maximum recommended alcohol intake is calculated on a daily rather than a weekly basis – men, three units a day; women, two units a day
- Unit measures of alcohol can be inexact so use formula (alcohol by volume (%) x volume in litres)
- Most detox programmes are home-based with professional support
- Alcoholism is rising among women, the elderly and men under 25
Days 1 and 2 - 20 mg qds
Days 3 and 4 - 15mg qds
Day 5 - 10mg qds
Day 6 - 10mg bd
Day 7 - 10mg nocte
Thiamine 100mg tds
Vitamin B complex one tablet tds
Ascorbic acid 500mg od
Strengths of drinks
- 500ml can of super strength lager 9%
- Half a pint of beer, lager, cider 3-3.5%
- One pub measure of spirit 38%
- One small glass of sherry 16%
- One standard glass of wine 16%