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Alcohol misuse: What can be done in primary care?

Key learning points:

 - Current guidelines on safe levels of drinking for men and women.

 - Recognising when alcohol use is becoming problematic getting patients to be honest about their drinking.

 - Helping patients cope with abstinence and withdrawal.

The start of a new year is a pertinent time to be thinking about what harm both we and our patients are doing to themselves through our drinking.

Our country's struggle with alcohol is increasingly evident in the media - for example, the recent British Medical Journal investigation into the government's u-turn on minimum unit pricing made headline news,1 and the frequent flyers to our emergency departments, relating to chronic alcohol use, are well reported.

In the UK, over 90% adults drink and one in four of us drink above daily recommended levels. Gimmicks such as 'dry January' can be useful to get us thinking and talking about alcohol more, but my feeling is that we all (society, not just health care professionals) need to talk about our drinking more throughout the year - and the effect it may be having on our health. 

It is somewhat arbitrary at which stage alcohol use becomes alcohol misuse, and probably different for each individual. But on a population basis, there is good evidence behind the national safe drinking guidelines that men should not drink more than three to four units a day and up to 21 units a week, while women should not drink more than two to three units a day and up to 14 units a week. It is well evidenced that drinking above these levels can contribute to all sorts of health problems, not just the obvious liver disease but over 60 other medical conditions including various cancers (breast cancer risk is increased 1.5 times), high blood pressure and its cardiovascular implications (stroke in women is increased fourfold).2

Recognising when alcohol use is becoming problematic 

Generally speaking, healthcare professionals need to have a low threshold for talking to patients about their drinking, and this will usually involve being opportunistic when this is not the main reason for them presenting. 

However there is an important link to make when alcohol underlies the reason for the patient attending, say with a sprained ankle after a tumble under the influence, or with alcohol induced dyspepsia. 

Around 40% of all A&E admissions (and >70% on Saturday nights) are related to alcohol in one way or another, and it is important to make sure the patient understands that - even if you are seeing them a week later in primary care. 

So how can you tell if someone has an alcohol problem? Rather than resorting to blood tests, by far the best screening tools involve simple sets of questions that have been well validated and have both good sensitivity and specificity.

A good one to have in your head is the modified single alcohol screening question (M-SASQ):3

 - For men: How often do you have EIGHT or more standard drinks on one occasion?

 - For women: How often do you have SIX or more standard drinks on one occasion?

(Where one standard drink equals one unit of alcohol).

If the patient's response is 'monthly', 'weekly' or 'daily or 'almost daily' the score is M-SASQ positive, implying they may have problem with alcohol and a more thorough history is needed. Only if their response is 'never' or 'less than monthly' the score is M-SASQ negative. However this may not be sensitive enough to detect the regular low-level wine or sherry tippler who may still be drinking two glasses of wine a night, which may well be taking people (especially women) over the safe levels.

The most widely used screening tool is probably the Alcohol Use Disorders Identification Test (AUDIT)3 tool; this 10-point questionaire only takes a few minutes to do and can give a useful objective measure of a person's drinking relative to previous occasions. 

When you are familiar with it you can mix it in with your conversation rather than sounding like an interrogation. If pushed for time the AUDITc - three questions taking half a minute - will flag up if there is a worrying departure from safe drinking levels; but it is the other seven questions that will also give some idea (to the patient as well as you) of the implications of their drinking.

Interventions in primary care 

To help our patients transcend the resistance we all feel to change our behaviour, it can be very helpful to make the relevant connection to flag up the health risks of heavy drinking. For example, I often hand out alcohol related calorie wheels to spell out the calorific effects of alcohol to someone overweight, or suggest that cutting down on alcohol may mean not having to have lifelong anti hypertensives because of the effect of alcohol increasing blood pressure.

So what can be done? Brief 'interventions' are now known as brief advice to make them sound less scary, and mostly involve talking to patients about the effect their drinking may be having on their health and eliciting what their response to that is. If there is some readiness to change then it's worth talking about some practical suggestions for cutting down and providing a helpful leaflet. 

Remarkably, brief advice has been shown to have a numbers needed to treat (NNT) of just one in eight, which is generally better than for smoking cessation, or asprin in secondary prevention of cardiac disease. So in general practice settings, for every eight individuals targeted with a brief intervention, one will significantly reduce their alcohol intake.4

Interestingly, longer counselling has little additional benefit. But this does not mean we should give up on dependent drinkers. In their latest set of alcohol guidance the National Institute for Health and Care Excellence are in favour of offering psychological interventions for those mildly dependent and suggest offering structured assisted withdrawal programmes for the more heavily dependent.5

This can and should be done in primary care with the key benefit that we see people on a longitudinal basis. After all, we see at least 75% of our practice population each year and this also allows for following up someone's problematic drinking. By appropriate read coding and recording of alerts that can 'pop up' when they attend, it is possible to pick up where you left off, especially as alcohol misuse tends to be a chronic relapse and remission problem that is very much affected by what's going on in the rest of peoples' lives.

Longer-term withdrawal and supporting recovery 

This is where some specialist help is often needed, although a GP experienced in alcohol misuse can handle the whole spectrum of problems.

There is an important discussion to be had on a very individual client basis to help decide whether more appropriate to aim for complete abstinence or controlled drinking. Peer mentoring, mutual aid groups and skilled alcohol counsellors can help with this.

In my practice for example, we regularly assess people who are dependent to see if they are suitable for community detox, where they are seen locally in the community on a daily basis, breathlysed before giving the appropriate amount of generally reducing medication (usually chlordiazepoxide [Librium] although sometimes a measured amount of alcohol is sometimes used) over the course of seven to 10 days.6

While most patients that have successfully battled with their dependent drinking have had to have more than one detox, it is important to try to avoid the 'serial detox' that can cause more harm than good through a kindling effect. This is a phenomenon of neural sensitisation, clinically manifest itself by progressive worsening of subsequent withdrawal episodes, particularly the predisposition to experience alcohol withdrawal seizures.7

It is really important to see people before/during and after a detox to address the crucial aspect of relapse prevention and whether the individual is aiming for complete abstinence or controlled drinking. Often, of course, it ends up not unlike a game of snakes and ladders with people falling off the wagon and climbing back on again.

I will finish this brief article with a positive case study to show that sometimes it pays to be opportunistic responding to an individual's readiness to change. A 24-year-old man attended our practice in a state of obvious early alcohol withdrawal, having just been discharged after 24 hours at the local hospital following admittance for alcoholic gastritis causing haematemesis. 

This had already had the effect on him of realising he needed to stop drinking and having tried unsuccessfully several times to stop or manage controlled drinking he was wanting complete abstinence. In these circumstances we either see the patient daily to breathalyse them and supply Librium or make use of a local community detox facility to do the same and provide psychosocial support. I managed to get him seen daily at the community detox facility. Ten days later he was free of withdrawal symptoms and ready to accept semi-supervised Antabuse to help support his ongoing abstinence.

If more training is what you need, there are various online (www.alcohollearningcentre.org uk) or sign up for the Royal College of General Practitioners (RCGP) certificate course which can often be run in your area if there is sufficient interest (or find a good local alternative). 

However as a first step, you could just try talking about alcohol more in your consultations - you will be surprised how many people are willing to discuss it, and you will get used to talking about alcohol until it becomes ingrained as a habit.

 

Resources

Change 4 Life: alcohol

National Institute for Health and Clinical Excellence (2011).

Alcohol use disorders: management of alcohol dependence

Screening and Intervention Programme for Sensible drinking (SIPS)

Alcohol Learning Centre

Nottingham's “Last Orders” service provide a one stop shop of alcohol services and advice and have devised a useful leaflet based on DOH guidelines

Nottingham's Alcohol community detox protocol

References

1. Gornall J. Under the influence. BMJ 2014;348:f7646.

2. Anderson P. The Scale of Alcohol-related Harm. [Unpublished] London; Department of Health: 2007.

3. PHE Alcohol Learning Resources

4. Moyer A, et al. Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction 2002;97(3):279-92.

5. National Institute for Health and Care Excellence. Alcohol use disorders: management of alcohol dependence. 2011. 

6. Alcohol community detox protocol

7. Ripley TL, Dunworth SJ, Stephens DN. Consequences of amygdala kindling and repeated withdrawal from ethanol on amphetamine-induced behaviours. Eur J Neurosci. 2002;16(6):1129-38.