In this series featuring information for patients and professionals taken from SIGN’s evidence-based guidelines, we reproduce the ‘notes for discussion with patients and carers’ section from SIGN guideline number 74, on management of harmful drinking and alcohol dependence.
Patient fears and perceptions when presenting with an alcohol problem
Research carried out by System Three Social Research, and the SIGN patient involvement project, commissioned by the Scottish Executive, has identified recurrent themes of concern to patients presenting with an alcohol problem.
There is a widespread acceptance that the GP is the most appropriate first point of contact once a patient has decided to seek help. However, there are considerable fears or reservations associated with seeking such help even where a good relationship exists with the GP. Such fears include:
- The normal shyness or hesitancy associated with a condition perceived to be ‘shameful’.
- Being labelled an ‘alcoholic’.
- Jeopardising one’s work by admitting to having an alcohol problem.
- Being concerned that children may be taken into care.
- Not being treated seriously or being told to ‘pull yourself together’.
Other general points to emerge from the SIGN research and the literature:
- Continuity of personnel providing support is essential as establishing trust is very important.
- Speed of referral is also very important as, once the difficult decision to seek help has been made, it needs to be followed up quickly or this positive attitude may evaporate.
- There are wide differences in understanding of the terms ‘alcohol misuse’,‘alcohol problems’ and ‘alcoholic’. A common usage is for alcohol misuse to mean ‘beginning to impinge on normal life’ and alcoholism to mean the above plus ‘a need or compulsion to drink’.
- There is confusion regarding what constitutes the standard unit of alcohol.
- Patients may have heard of Alcoholics Anonymous but will rarely have any knowledge of its methods or operations.
- There is widespread belief that there are substantial facilities for sufferers from drug abuse but very little for those with alcohol problems.
Key messages for patients
Problems with alcohol are suffered by people in varying degrees, ranging from occasional excess consumption to an addiction or dependence, which may affect the person and their whole lifestyle.
Patients often progress from mild misuse of alcohol to more extreme stages so it is important to try to address any problem at an early stage, seeking medical assistance where necessary.
Effects on the person
At a personal level alcohol misuse has many effects including:
- Anxiety, which often leads to a compounding of the problem.
- Health problems caused by the alcohol consumption itself including liver and brain damage and other serious conditions such as epilepsy and heart disease.
- Consequential health problems caused by the effects of alcohol such as malnutrition, injuries and gaps in memory.
- Difficulties in sustaining employment.
Effects on the family
Having a family member with an alcohol problem can seriously affect the family, where family members and friends can become anxious, depressed or alienated. Financial problems caused by the purchase of alcohol, coupled with reduced earnings potential also impact on the family.
Help available from the primary care team
The range of advice, treatment and referral available from the GP and the primary care team includes:
- Initial discussion and support.
- Advice regarding non-hazardous drinking levels and ways to reduce drinking.
- Counselling and therapy for the individual.
- Counselling and therapy for the family.
- Treatment options including medication to relieve the physical effects of stopping drinking and to help to reduce the incidence of drinking in the longer term.
- Referral to a specialist nurse, often within the practice, for individual help.
- Referral to another agency for clinical care with information about treatment options available.
- Lay counselling.
- Link with a mutual help association such as Alcoholics Anonymous.
- Longer term support and monitoring.
It should be stressed to patients that stopping or cutting down their drinking can only result from their own decision to do so. Any treatment, from whatever source, can only be an aid to taking this decision and following it through.
The drinker’s family may seek advice on how they should intervene when the drinker is not motivated to change. ‘Detaching with love’ (one of the principles by which Al-Anon members lessen the risk of harm to their own mental health resulting from living with a drinker), or simple confrontation, are less likely to get the drinker to change or seek help than using an approach based on community reinforcement and family training (CRAFT).
Although not tested in primary care, the method can be taught to nonspecialists.
CRAFT instructs the family or ‘committed significant other’ to reinforce, by encouragement or other rewards, any changes or statements that the drinker makes towards stopping or reducing the drinking, and to do nothing to enable or reward drinking.
The treating team lays down the groundwork for rapid availability of outpatient treatment for the drinker in the event that he or she opts to begin therapy.
The family are prepared from the beginning to recognise and respond safely to any potential for domestic violence during the introduction of what may be a new way of reacting to the drinker and the drinking. The family are helped to:
- Understand the nature of alcohol dependence.
- Improve communication with the drinker.
- Selectively apply or withdraw reinforcement, to amplify nondrinking.
- Apply pressure without bickering or recrimination.
- Learn stress reduction and gain more reward in their own life.
- Use effective methods and optimal times for proposing treatment entry to the drinker, such as restricting key messages to moments of sobriety, and exploiting alcohol related crises.
- Support the drinker through treatment.
The following recommendation has been extrapolated from the above trials.
- The primary care team should help family members to use behavioural methods which will reinforce reduction of drinking and increase the likelihood that the drinker will seek help.
|Sources of useful information|
Mansfield Park, Unit 6, 22 Mansfield Street, Glasgow G11 5QP
Support for families and friends of alcoholics
National helpline: 0845 76 97 555
Provides information on a wide range of alcohol related subjects.
Alcohol Concern does not operate a helpline.
Alcohol Focus Scotland (formerly the Scottish Council on Alcohol)
National Alcohol Information Resource
Adapted from SIGN 74. Management of harmful drinking and alcohol dependence in primary care – A national clinical guideline. Edinburgh: Scottish Intercollegiate Guidelines Network, 2003.