Guidelines drawn up by Dr Jez Thompson's practice for its in-house alcohol service have increased the partners' confidence in assessing and managing problem drinkers

In the UK, 27% of men and 14% of women drink more than the accepted healthy amounts of alcohol, and at least 6% of men and 2% of women drink more than double the safe limit,1 which puts them at significant risk from adverse physical, psychological and social effects.

Current government advice on safe drinking is <28 units per week for men and <21 units per week for women. The Royal Colleges advise <21 units and <14 units per week respectively. Some authorities advise in addition at least two alcohol-free days every week, and no more than 8 units on any occasion.

Between 10% and 20% of people consulting their GP drink more than the recommended upper limits,2 yet much of this health risk goes unnoticed in primary care.3

St Martin's Practice drug and alcohol service

For four years my practice has run a specialist drug and alcohol service in parallel with routine general practice services, and patients presenting with established problem drinking have been referred to the in-house addictions therapist.

She has been able to see patients promptly, and to formulate a management plan in conjunction with the GP, which has benefited both patients and staff.

Over the past year we have been thinking about drawing up guidelines for the management of at-risk and problem drinkers. This has presented us with a number of challenges: in particular, we have had to question the way we identify and manage at-risk drinkers and have firmed up and standardised our procedures for community detoxification.

We consulted various issues of the Drug and Therapeutics Bulletin and the WHO guidelines,4 but no guidelines were totally appropriate for our needs as GPs. In writing the guidelines we were able to acknowledge the value of our own experience, and this has made them more personal and valid.

Problems with establishing the guidelines have been the usual ones of limited time and energy, and also ownership.

All partners in the enterprise need to be fully engaged in the processes of both writing and implementation in order for the guidelines to produce results. And that means making time for discussion, review and further discussion.

It is only a short while since the guidelines were written and it is too early to audit their impact, but I feel that we now have a higher awareness of at-risk drinking, are more likely to ask about alcohol use in consultation, and have better structures for the delivery of appropriate interventions for at-risk and problem drinkers.

Our summary of terms associated with alcohol use and misuse, and some of the health effects, can be found in Figure 1 (below).

Figure 1: Summary of terms associated with alcohol use and misuse and their health effects

Moderate drinking

Drinking within accepted 'safe limits' – definitions vary: current UK government advice is <28 units per week for men and <21 units per week for women. The British Royal Colleges advise <21 units and <14 units per week respectively. Some authorities advise in addition at least two alcohol-free days every week, and no more than 8 units on any occasion. May be associated with increased risk of upper gastrointestinal cancer9 and reduced fertility for women10, though may also be associated with better lipid profiles and lower mortality rates from ischaemic heart disease, and lower all-cause death rates.11
Heavy, hazardous or at-risk drinking Drinking at levels significantly above defined 'safe limits'. There may be no current alcohol-related problems, but a heavy drinker is at increased risk of the adverse social, psychological and physical effects associated with alcohol, and in particular has a higher long-term risk of stroke and coronary heart disease.12
Intoxication Acutely high alcohol levels resulting in poor judgment and self-control, and ultimately loss of consciousness. May be associated with regular heavy drinking, binge drinking or problem drinking, or may be isolated and followed by long-term remorse. Association with driving offences and accidents, aggressive and violent behaviour, acute situational disturbance, risky sexual activity and parasuicide. Additional dangers are of unconsciousness and inhalation of vomit.
Binge drinking Excessive drinking in short bouts, often over 24–48 hours, with sometimes lengthy periods of abstinence in between. Average weekly intake can still be below 'safe limits'. Has a similar risk profile to intoxication, and in addition may cause significant social, employment and relationship disruption.
Problem or harmful drinking, problem alcohol use or alcohol misuse Drinking sufficient to cause current social, physical or psychological harm, to self or to others. Personal, family, work and financial problems may be common with added dangers from injuries, accidents, violence and crime, all associated with loss of control. The problem drinker is at significant risk from psychological difficulties including depression and suicide.13 Anxiety and sleep disturbance are common, as are emotional and behavioural disturbance in children and young people who drink heavily. Health risks include liver disease, pancreatitis, gastritis, peptic ulcer disease, hypertension, hypertriglyceridaemia, adult-onset epilepsy, collapse, progressive damage to brain tissue and dementia, erectile dysfunction and peripheral neuropathy. Women may have low birth weight babies or babies with fetal alcohol syndrome.
Alcohol dependence syndrome, alcoholism Syndrome characterised by a compulsive need to drink, stereotyped pattern of alcohol use with little control, primacy of drinking over other activities and concerns, tolerance to effects (a patient may no longer get drunk despite extensive intake), withdrawal symptoms and shaking in response to falling blood levels (typically 8–12 hours after stopping drinking), which may be associated with relief drinking, withdrawal fits or delirium tremens. With alcohol dependence the compulsion to drink is highly likely to have caused highly significant social and relationship damage which may include job loss and family breakdown. The alcohol-dependent patient is at high risk of the mental and physical health problems associated with harmful drinking.
Dual diagnosis

The coexistence of problem alcohol use (or other substance misuse) with mental health problems.

Problem drinking is significantly associated with depressive illness, schizophrenia, and personality problems. It may not be clear what is the cause and what is the effect, and both problems need appropriate management. Suicide is a real risk.13

 

Identifying at-risk and problem drinkers

Recent work indicates that general practice-based interventions can be successful in cutting patients' drinking5 and GPs are agreed that primary care is the place for alcohol advice to be given.3 Appreciating these facts has helped me in taking guidelines into my personal practice. Figure 2 (below) shows our case-finding strategy.

Figure 2: Extract from the St Martin's Practice Drug and Alcohol Service – case finding
case finding

When we discover that a patient is drinking more than healthy limits we assess any health and social consequences. It may be particularly useful to find out what worries the patient particularly about his/her drinking – a patient's own fears may help provide the best motivation to cut drinking. It is particularly important to note the severity of any previous withdrawal symptoms before embarking on a plan of cutting drinking.

The role of investigations

Most GPs have traditionally performed blood tests as part of the assessment of problem drinking. However, they are of little real value in establishing a diagnosis of problem drinking,7 though they may have some use in confirming a clinical suspicion, or in showing a drinker evidence of personal physical harm related to alcohol. We continue to perform blood sampling, though aware of its limitations.

Choosing interventions

Our guidelines focus on a small range of interventions. The decision to use one intervention rather than another depends on the doctor's assessment of the patient's needs.

Brief interventions

These may involve only one or two appointments in identifying alcohol intake and in providing advice. They may be particularly suitable for at-risk drinkers whose drinking habits are not strongly established and who have no evidence of alcohol-related harm.

Advice may be very simple, e.g. discussion of recommended limits and the dangers of drinking too much, together with clear advice to cut down. This may be backed up by one of the many good leaflets available. This has been a traditional part of general practice, takes little time, and can result in a significant reduction in alcohol intake.8

Motivational interviewing

Some patients, particularly those with a longer history of heavy drinking, find it hard to respond to brief advice, and may need a supportive, listening atmosphere over a series of appointments to contemplate the costs of continued drinking.

GPs in the practice may take this on themselves, although the pace may be slow and there may be setbacks. Alternatively we refer patients to the addictions therapist, where other GPs may choose referral to a local alcohol agency. The focus is on improving a patient's motivation to change, developing his/her self-confidence, and setting and supporting clear targets for change.

Skills training

Although some patients will have a clear idea of how they want to reduce their drinking, others may need help, and our guidelines suggest a number of simple behavioural strategies such as having at least three alcohol-free days and alternating between alcoholic and non-alcoholic drinks.

Other resources

Some patients may want to find out more information for themselves and a good website to visit is: www.downyourdrink.org. It provides clear information about safe alcohol use, means of assessing your own drinking, and a 6-week plan for reducing consumption.

Detoxification

If alcohol use has been moderate, and there have been no previous withdrawal symptoms, stopping drinking is unlikely to be complicated, and a patient can be supported through the process with an explanation by the GP of likely symptoms, advice about hydration and nutrition together with support and encouragement.

Because of the special interest of the practice we feel comfortable in managing a moderate withdrawal syndrome in the community, with the support of our addictions therapist.

Withdrawal symptoms can be reduced and modified by the prescription of an oral, long-acting benzodiazepine: a typical regimen is given in Figure 3 (below), although specific dosage will depend upon weight, gender, liver function and withdrawal severity. We tend to see patients on a daily basis, and make firm arrangements for the daily collection and safe administration of prescribed drugs.

Medical complications during a community alcohol detoxification may require acute admission.

Figure 3: Typical chordiazepoxide regimen for community alcohol detoxification
Days 1 and 2 20-30mg qds
Days 3 and 4 15mg qds
Day 5 10mg qds
Day 6 10mg bd

Day 7

10mg nocte

Other prescribing in problem alcohol use

Patients with chronic heavy drinking are often malnourished and deficient in vitamins, especially thiamine. We prescribe oral thiamine (200µg daily) together with vitamin B co forte (one three times daily), for one month, for all patients undergoing community detoxification.

We also consider prescribing longer-term vitamins for patients who are drinking heavily but are not able to cut down. As an additional benefit, seeing a patient for a regular prescription may keep open a doorway for further discussion about alcohol use.

Disulfiram may be effective in helping some patients maintain abstinence. Assessment and initiation of treatment should be through a specialist, although a GP may be asked to help in monitoring and supervising treatment. We test liver function regularly (every 3-6 months) during treatment, and stop treatment if liver enzymes are significantly altered.

Acamprosate can reduce the craving for alcohol in dependent drinkers. When combined with a programme of psychosocial support, it can help maintain abstinence or controlled drinking. Again, treatment is likely to be started by a specialist agency, although we are happy to monitor and support the patient.

Because of the possibility of misuse, diversion of tablets onto the street and addiction, we avoid prescribing benzodiazepines unless part of a community detoxification.

Many drinkers are depressed, and if oral therapy is needed, we choose a selective serotonin reuptake inhibitor, because of the interaction between alcohol and tricyclic antidepressants.

Referral agencies

It may be appropriate to refer some patients to an agency for help with problem drinking. Many areas will have locally based statutory or voluntary services which take referrals and self-referrals for alcohol problems. Other resources include:

  • Alcoholics Anonymous, which is based on mutual support through group work, and focuses on abstinence. Tel 01904 644026; national helpline 0845 7697 555
  • Al-Anon provides supportive group work for relatives of people with a drinking problem. Details of groups can be obtained by phoning 020 7403 0888

Conclusion

We have found the management of at-risk and problem drinking rewarding, and our practice has improved through the process of formulating guidelines. Although our patients still have setbacks, we feel more confident in assessing and managing them.

For an information pack containing our guidelines, contact Angela Walker, Practice Manager, St Martins Practice, 319 Chapeltown Road, Leeds LS7 3JT (tel: 0113 2621013, fax: 0113 2374747, email: angela.walker@gp-b86100.nhs.uk

References

  1. Office for National Statistics. Social Survey Division. Living in Britain. Results from the 1996 general household survey. London: The Stationery Office, 1998.
  2. Curry SJ, Ludman E, Grothaus L. At-risk drinking among patients making routine primary care visits. Prev Med 2000; 31(5): 595-602.
  3. Deehan A, Templeton L, Taylor C. Low detection rates, negative attitudes and the failure to meet the 'Health of the Nation' targets: findings from a national survey of GPs in England and Wales. Drug Alcohol Rev 1998; 17: 249-58.
  4. WHO Collaborating Centre at the Institute of Psychiatry. WHO Guide to Mental health in primary care (adapted for the UK, with permission, from: World Health Organization. Diagnostic and Management Guidelines for Mental Disorders in Primary Care: ICD-10. Chapter V, Primary Care Version).
  5. Wutzke SE, Shiell A, Gomel MK. Cost effectiveness of brief interventions for reducing alcohol consumption Soc Sci Med 2001; 52(6): 863-70.
  6. Aertgeerts B, Buntinx F, Ansoms S. Screening properties of questionnaires and laboratory tests for the detection of alcohol abuse or dependence in a general practice population. Br J Gen Pract 2001;51: 172-3.
  7. Conigrave KM, Saunders JB, Whitfield JB. Diagnostic tests for alcohol consumption. Alcohol alcohol 1995; 30: 61-6.
  8. Nuffield Institute for Health, Centre for Health Economics, Royal College of Physicians. Brief interventions and alcohol use. Effective Health Care 1993; 1: 1-14.
  9. Grønbæk M, Becker U, Johansen D et al. Population based cohort study on the association between alcohol intake and cancer of the upper digestive tract. Br Med J 1998;317:844-8
  10. Jensne T, Hjollund N, Henriksen T et al. Does moderate alcohol consumption affect fertility? Follow up study among couples planning first pregnancy. Br Med J 1998;317:505-10
  11. Doll R, Peto R, Hall E et al. Mortality in relation to consumption of alcohol: 13 years' observations on male British doctors. Br Med J 1994;309:911-18
  12. Hart C, Smith G, Hole D, Hawthorne V. Alcohol consumption and mortality from all causes, coronary heart disease and stroke: results from a prospective cohort study of Scottish men with 21 years follow up. Br Med J 1999;318:1725-9
  13. Foster T. Dying for a drink. Global suicide prevention should focus more on alcohol use disorders. Br Med J 2001;323:817-8

Guidelines in Practice, January 2002, Volume 5(1)
© 2002 MGP Ltd
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