Preventing CHD deaths: does healthy living trump anything GPs can offer?
Consultation about alcohol abuse
Establishing why a problem drinker is attending and what they are looking for by Dr Melanie Wynne-Jones
Many patients have problems with alcohol, including increasing numbers of teenagers and young adults, although most do not present spontaneously asking for help. More frequently they consult under pressure because their alcohol-related behaviour has harmed them or upset someone else. They often surface as 'emergency extras' or out-of-hours callers, so it's worth asking why, and why now?
They may have developed physical illness such as dyspepsia, pancreatitis, cardiovascular disease, alcohol-related injury or even overt liver failure. Or they may be anxious, depressed, aggressive or paranoid as a result of, or as the underlying cause for, their drinking using alcohol as self-medication for distress or mental illness is fairly common.
Their partner or family may have given them an ultimatum, or they may be in trouble with the law for fighting, drink-driving and so on. They may also be abusing other substances cannabis is probably the commonest. There are several tasks to achieve in this consultation:
· Establish the reason for their attendance and what they are looking for
· Find out how much they are drinking (they may not be truthful)
· Put this into context their background, current situation and support network
· Decide whether they have an urgent/longer-term mental health problem requiring psychiatric help.
· Assess their risk of self-harm
· Decide whether they have an urgent/longer-term physical problem requiring investigation or treatment
· Assess motivation for cutting down or stopping
· Negotiate a way forward.
Clearly this will take time, and may require more than one appointment, although a physical or mental problem may demand immediate attention.
A big problem for GPs (and accident/emergency staff) is the patient, often out-of-hours, who is drunk and threatening self-harm, or who refuses to accept medical examination or treatment (for example, of a head injury) which is clearly in their best interests.
The Mental Health Act does allow compulsory admission to hospital for assessment under section 2 or 4, but someone who is drunk cannot be assessed under the Mental Health Act and may require a period of observation in a place of safety until they sober up. You may need to liaise with hospital specialties, including the on-call psychiatrists, and/or the police.
Solving this can be quite a challenge and you will probably need your trainer's help. Anxious relatives who can no longer cope, or who expect a purely medical solution, are another form of pressure.
If this isn't actually a crisis situation, or at a later date, the patient may be willing to discuss their drinking. The CAGE questionnaire is often used as a simple screening tool, or as a non-confrontational way of asking about someone's drinking:
· Have you ever thought about Cutting down on your drinking?
· Have you ever been Annoyed by criticism of your drinking?
· Have you ever felt Guilty about your drinking?
· Do you ever have a drink in the morning (an Eye opener)?
Ask what exactly they drank each day in the previous seven days (some lagers, ciders and red wines are extra strong). Are they steady heavy drinkers or binge drinkers? How long have they been drinking at this rate? Do they have hangovers, night sweats or withdrawal symptoms? Have they kept up with their responsibilities, or been in trouble at work, at home or with the law?
Finally, do they see their drinking as a problem, and how motivated are they to address it? Have they tried? What happened?
Each PCT has a community alcohol team (CAT) that can provide support and advice for people with alcohol problems, and/or supervised detoxification which may be performed in hospital or at home. You may be asked to prescribe benzodiazepines to cover a home detox; this is potentially a risky situation and you will carry the medicolegal responsibility. Again, you should discuss this with your trainer. In some areas, this may have been negotiated as an enhanced service.
Alcoholics Anonymous meetings provide support, but don't suit everyone; Al-Anon will provide confidential support to family members. The CAT should have local contact details.
If the patient is not actually willing to be referred to the CAT at present, then information and health promotion advice about alcohol may be all you can provide at present.
PRODIGY guidance (see references) covers the identification and management of hazardous and harmful drinking, with or without alcohol dependence. It also covers alcohol detoxification in primary care and the maintenance of abstinence following detoxification.
Melanie Wynne-Jones is a GP in Marple, Cheshire
References and resources
PRODIGY Guidance Alcohol Problem Drinking June 2004. Based on the Scottish Intercollegiate Guidelines Network (SIGN) Guideline The management of harmful drinking and alcohol dependence in primary care (September 2003). www.prodigy.nhs.uk/guidance.asp?gt=Alcohol%20-%20problem%20drinking
Institute of Alcohol Studies www.ias.org.uk
Alcohol Concern the national agency on alcohol misuse www.alcoholconcern.org.uk
AA Alcoholics Anonymous Tel: (National Helpline): 0845 769 7555 Web: www.alcoholics-anonymous.org.uk