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Three GPs share their approach to a clinical problem

Case history

Mr Spencer has been alcohol dependent for some time. He has seen a liver specialist about his abnormal liver function and has had a gastroscopy that confirmed gastritis. But he has defaulted from seeing both specialists, as well as the psychiatrist and the community alcohol team.

He frequently attends the surgery, often at the insistence of his worried family who say 'something should be done'. Recently he (and they) have been demanding emergency appointments because he is 'ill', but the problem always turns out to be more of the same, or because he wants something for his 'nerves'.

He continues to drink, and is now appearing as an 'extra' two or three times a week.

Dr Richard Stokell

'I would ask him: What are you going to do about your alcohol problems?'

I need to know more about Mr Spencer to complete the picture and to allow me to generate management options. I need information about his alcohol intake and his overall physical health. I also need to know about his mental state and social circumstances in order to assess his risk.

The case can be considered as the patient's problems, the family's problems and the doctor's problems. I would try to see Mr Spencer in surgery with a close family member. I know he won't stop drinking until he is ready. My job is to offer advice about the effects of his behaviour on his health and suggest ways in which he might change. I would ask him: 'What are you going to do about your alcohol problems?'

His family are feeling upset and powerless. Explaining this approach is likely to lead to an empathic discussion with them about how frustrating I find looking after Mr Spencer and should sidestep the pressure to 'do something' to him.

The other issue is his frequent emergency appointments. I would suggest to Mr Spencer that there is no point in coming back to the surgery until he is ready to change.

If he is ready to engage in treatment, our options are community detoxification followed by counselling or support from Alcoholics Anonymous, or admission. This decision depends on his social circumstances and my assessment of his physical health.

For community detoxification it is often best to use a specialist local service. If I was supervising it I would prescribe a chlordiazepoxide reduction regime only if he was sober at presentation in surgery, and would see him on day two and day seven. If he could stay more or less alcohol free for seven days I would allow him to tail off the chlordiazepoxide over three or four days.

Again, I would assess his mood, offer follow-up of his liver problem and offer support via Alcoholics Anonymous or the local alcohol service. At this stage I would tell him that relapse is inevitable, and challenge him to last as long as possible without drinking. I would, however, advise him to come back if he does relapse before he sustains further damage.

Richard Stokell completed the VTS in 1988 and currently practises in Birkenhead, Merseyside ­ he is also a GP trainer and course organiser

Dr Jo Thomson

'I would remind him that his addiction is damaging his health'

The word 'heartsink' springs immediately to mind. Although I haven't got to the bottom of Mr Spencer's problems I have obviously known him for some time, having made numerous referrals in the past. I would ask myself why he keeps coming in as an extra and defaulting on his hospital appointments ­ then I would ask him the same questions.

He must decide whether he actually wants help and is willing to stop drinking. His family may be at the end of their tether, but perhaps I need to point out that the commitment must come from him before any progress can be made. I would remind him that his alcohol addiction is damaging his health.

What kind of rapport have I got with him? If I see him as a heartsink patient it may hamper my consultation style, which is something I would have to address. His frequent attendances may be a cry for help.

Asking for treatment for his 'nerves' could indicate an addiction to benzodiazepines as well as to alcohol. I could take the easy way out and give him anxiolytics, but my conscience would make me cautious and I would check whether I, or my colleagues, have given them to him in the past. Alcohol misuse or withdrawal can itself cause anxiety, but he may have suicidal tendencies.

I need to spend time exploring why he keeps coming in. To do that in the time constraints of emergency surgery may be difficult, but spending those extra few minutes could pay dividends for the future.

I would ensure an open consultation style, while setting boundaries for future appointments. If he is drunk when he comes in I would probably refuse to see him until he is sober because neither of us would be likely to gain from the consultation.

Jo Thomson completed the VTS in 2001 ­ she is a part-time salaried GP in Hurstpierpoint, West Sussex

Dr Rodger Charlton

'The GP is often the only ''friend'' these patients have left'

Helping patients with severe alcohol problems is hard work and frequently unrewarding because of the high relapse rate. Having said that, my experience is that these people can seldom help themselves and have a high morbidity, with many dying young.

This case illustrates a recurring situation for me. Patients like Mr Spencer default attendance at the hospital psychiatry clinic and the community alcohol team and then the GP receives a letter saying they have been discharged from follow-up. And yet it is these high-risk patients who most need follow-up.

I would write to the hospital and ask them to send Mr Spencer further appointments, and I would also write a personal letter to Mr Spencer explaining how important specialist help is. I would repeat this message if I see him in the meantime or to his family next time they tell me 'something should be done'.

Perhaps the crux of people dependent on alcohol is our limited understanding of their problem and the fact that treatment seems to have little success. This compounds our negativity and we view them and their families as demanding, as in Mr Spencer's case. Is it that we don't perceive alcohol dependence as a disease or medical problem, but rather see it as a social disorder?

Family and carers desperately seek a rational explanation for the behaviour, overlooking the fact that alcoholism is a disease with limited treatment options. As unrewarding and irritating as it may be, the GP is often the only 'friend' they have left and all we can do is to keep seeing them even if it is an extra two or three times a week. Otherwise they could end up in a hostel, sleep rough on the streets or die.

Rodger Charlton has been a GP for 16 years ­ he is a part-time principal in Hampton-in-Arden, West Midlands, and a senior lecturer at the University of Warwick medical school

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