Problem and dependent drinking
In the first of a two-part article,Dr Clare Gerada provides practical advice on how to recognise and support problem drinkers
Most adults drink, and most drink sensibly, although about 21% of men and 17% of women drink more than 'sensible' daily limits of two to three units per day for women and three to four units per day for men.
Calculating how much alcohol is drunk is not as easy as it first appears. Most people equate one drink (half a pint of lager or one glass of wine) as being equal to one unit. But using this rough-and-ready method will greatly underestimate amounts drunk. It is important to take into account the volume or size of the glass and the strength of the alcohol being drunk.
One unit of alcohol is 10ml (1cl) by volume, or 8g by weight, of pure alcohol. A more accurate way of calculating units is as follows. The percentage alcohol by volume (% ABV) of any drink equals the number of units in a litre of that drink. For example:
•Strong beer at 6% ABV has six units in one litre. If you drink half a litre (500ml) – just under a pint – then you have had three units (500/1,000x6).•Wine at 12% ABV has 12 units in a litre. If you drink a quarter of a litre (250ml) then this is equal to three units (250/1,000 x 12).
Identifying the heavy drinker
James is 42 and works very hard in the City. He consults complaining of headaches, and investigation shows that he is hypertensive, has a cholesterol level of 7.8mmol/l, high MCV and abnormal liver enzymes. He has never had a day off work and considers himself to be very fit, playing squash every Sunday and going to the gym at least twice a week.
When asked about alcohol, he says 'Oh, I don't drink any more than my friends', but it transpires that he drinks every day – a quick beer on his way home from work, a gin and tonic when he gets home, a bottle of wine shared with his wife over dinner and sometimes a small whiskey before going to bed. He is asked to keep an alcohol diary, and his entries for the week are shown on page 55.James should be diagnosed as a heavy drinker. He may be a dependent drinker. As a GP, your role is critical. Feeding back to him that he is drinking at least double the weekly recommended amounts for a man, and that his alcohol intake is beginning to show in his physical health, is an important first step and can have a powerful influence on his future drinking pattern. Brief interventions are very effective in helping non-dependent patients and can be delivered in a 10-minute consultation (see box Interventions, page 55).
Helping the dependent drinker
Mary is a 36-year-old nurse working in the A&E department at the local hospital. She comes to consult complaining of severe gastritis. It is 3pm and there is a smell of alcohol on her breath. When questioned, she replies: 'Oh, I've finished work for the day and I went to a leaving do at lunchtime.'
You make a note of this in the records but in doing so scroll back a few consultations and find that your partner commented on her smelling of alcohol during a Monday morning consultation some time back. You persevere and broach the subject again. Mary begins to cry. She admits she is finding it tough working full-time and being a mother and wife. She is finding that she needs to drink to get through the day and to stop feeling lousy in the morning.She doesn't want you to tell anyone in case she loses her job and her marriage. She doesn't really know what to do, but promises to stop drinking straight away.So how can you be sure Mary is a dependent drinker, and what interventions can you offer?Mary has made an enormous step forward in admitting that she may have a drink problem. As her GP you have helped her disclose that she is drinking too much. If Mary had not disclosed this herself, a useful question to ask is 'Have you or others ever been concerned about your drinking?' Or say: 'We often find that people's drinking, eating and smoking habits have effects on their health – I would like to ask you some questions.' If dependence is suspected, as in Mary's case, useful questions include:
•Do you crave alcohol?•Have you been unable to stop drinking once you have started?•Do you skip meals because you are drinking?•Do your hands shake in the morning? •Do you ever feel you need a drink in the morning to settle your nerves?•Have you ever felt guilty about your drinking?
Dependent drinking is characterised by:
•craving•withdrawal symptoms on cessation•drinking to offset withdrawal•reinstatement after a period of abstinence (this means drinking in the same way almost immediately after abstinence)•stereotypical pattern to drinking (same amount, same drink, same pattern)•drinking takes precedence over all other activities•tolerance.
The move from problematic (as in James's case) to dependent drinking can be gradual, the important issue being that once dependent it is unlikely that the individual can participate in controlled drinking and must assume lifelong abstinence. Having diagnosed Mary as a dependent drinker, treatment options include community detoxification followed by support to help her remain abstinent. Community detoxification can be safely carried out by GPs using short courses of benzodiazepines and will be discussed in next week's article.
Support in the community
The GP's role should be to identify the problematic and dependent drinker, followed by support to help reduce alcohol consumption in the non-dependent drinker and help the dependent drinker detoxify and remain abstinent.
Dr Clare Gerada is a GP in south London, RCGP lead on substance misuse and chair of the RCGP medical ethics committeeCompeting interests None declaredThis article is based on a presentation 'How to support the detoxing drinker in the community' given by Dr Clare Gerada at a Pulse seminar on 31 January 2007 at the Royal Society of Medicine, London. To register for the next Pulse seminar, Hot topics in clinical practice, see page 69Next week: Dr Gerada explains how to do alcohol detoxification in primary care
Brief intervention involves the following elements:• Feedback: assessment and evaluation of the problems (keep a drink diary, discuss effects on the individual)• Responsibility: emphasising that drinking is their choice• Advice: explicit advice on changing drinking behaviour (for example, buy half bottles of wine, use a measure to calculate 'one' drink when drinking spirits at home, do not use a wine box)• Menu: offering alternative goals and strategies• Empathy