Problem drinking is a major health issue in the UK, with up to 20% of the population drinking more than the recommended limits.1 It is a common cause of physical, psychological and social harm, and the incidence of alcohol-related death is rising sharply.2
Heavy drinkers consult their GPs twice as often as other patients in a practice,2 and we are well placed to identify problems early. However, evidence shows that many cases go undetected in primary care.3 It is easy to cite lack of time and a reluctance to pry as excuses for failing to spot alcohol-related symptoms. You also need to feel confident that your advice will improve the situation.
To help GPs tackle the problem, SIGN has published The management of harmful drinking and alcohol dependence in primary care.2 Like all SIGN guidelines the membership of its development group is impressive and includes specialists, generalists, nurses and lay people, and it underwent a robust consultation process. The document is well referenced, and recommendations are graded according to the strength of the underpinning evidence.
Much of the advice in the guideline is practical, for example how best to handle an intoxicated patient on the phone or in the surgery. I found the introductory paragraphs on terminology useful reminders,and the guidance about alcohol units enlightening – some alcoholic drinks have become stronger, and standard measures larger, in recent years.
I have worried that patients would underestimate their alcohol consumption when asked, and even resent the question. The guideline provides reassurance that few are offended by a non-judgemental question, and offers suggestions on how to obtain an accurate alcohol history. I had already come across the AUDIT questionnaire, but found it too time consuming to use, so I was delighted to find references to a number of much shorter, but well validated, screening tools.
Of particular interest to me was the evidence base for brief interventions in routine consultations,which shows that they are effective. These interventions can be very simple, for example advising the patient about recommended limits, alcohol-related harm and cutting down.
The guideline also provides information about counselling techniques for those patients with a more serious problem, and makes excellent practical suggestions for practitioners with a special interest. In addition, there is very clear information about detoxification, both with simple support and with benzodiazepines, and there are clear protocols on when to refer.
My one disappointment is the section on co-existing alcohol dependence and depression. Standard advice to help the patient stop drinking before considering antidepressant treatment is there, but the guideline fails to address the familiar issue of the depressed patient who refuses to stop drinking. Do we use antidepressants or not?
Overall, the guideline is easy to read and the supporting summary, handy for the consulting room, contains many useful tips. The tone of the guideline is inclusive throughout, setting standards for good practice and providing encouragement for those practitioners with a special interest.
After reading the guideline I shall be more likely to ask about alcohol consumption and to use a validated screening tool. I shall also be more confident that a brief intervention will have a beneficial effect.
- Office for National Statistics. Social Survey Division. Living in Britain. Results from the 1996 general household survey. London: The Stationery Office, 1998.
- Scottish Intercollegiate Guidelines Network. SIGN 74.The management of harmful drinking and alcohol dependence in primary care. Edinburgh: SIGN, September 2003.
- 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. 1