Dr Stephen Willott provides 10 top tips for assessing alcohol dependency in primary care including how to manage patients presenting in crisis

Willott_Stephen

Figure 2: The ‘toxic trio’

8. Assess the patient’s fitness to drive

For some people, driving is not only a matter of their independence, but their livelihood and some are fearful of losing their licence if it is confirmed that they have an alcohol problem. While GPs are not law enforcement officers, they do have a duty not only to help the patient but to safeguard others. Try to discuss driving with the patient and encourage them to contact the DVLA themselves. Anyone can alert the DVLA and raising a concern does not mean that the person loses their licence. If, as a GP, you raise a concern with a patient and ask them to contact the DVLA but do not receive a form back to complete, then it is safe to assume the patient has not contacted the DVLA and you may need to consider taking action.

Where there are signs of persistent driving with an alcohol misuse problem, the DVLA guidance is clear—the person should not drive for at least 6 months (1 year in the case of bus or lorry drivers). If alcohol dependence is confirmed, their licence will be refused or revoked until after at least 1 year free of alcohol problems (3 years for bus or lorry drivers) (see Table 1).3

There are situations where it is necessary to break confidentiality and call either the DVLA or the police (or both), for example, when a patient is clearly driving (or intending to drive) while intoxicated. The General Medical Council published Confidentiality: patients’ fitness to drive and reporting concerns to the DVLA or DVA, which provides guidance about the role of doctors in disclosing this information.37  If there was a fatality involving a drunk driver, the coroner could reasonably ask a GP why the DVLA or police were not informed.

The DVLA’s medical advisers can be contacted on 01792 782 337 or at medadviser@dvla.gsi.gov.uk, and the Driver and Vehicle Agency (Northern Ireland) on 0800 200 7861.

Table 1: Assessing fitness to drive in people who persistently misuse alcohol and people with confirmed alcohol dependence3

 Group 1: car and motorcycleGroup 2: bus and lorry

Persistent alcohol misuse confirmed by medical enquiry and/or evidence of otherwise unexplained abnormal blood markers

Must not drive and must  notify the DVLA.

Licence will be refused or  revoked until after:

  • a minimum of 6 months of controlled drinking or abstinence, and
  • normalisation of blood parameters.

Must not drive and must  notify the DVLA.

Licence will be refused or  revoked until after:

  • a minimum of 1 year of controlled drinking or abstinence, and
  • normalisation of blood parameters.

Dependence confirmed by medical enquiry

Also refer to alcohol-related  seizure guidance (see www.gov.uk/guidance/drug-or-alcohol-misuse-or-dependence-assessing-fitness-to-drive#alcohol-related-seizure)

 

- Must not drive and must notify the  DVLA.

Licence will be refused or revoked until after a minimum of 1 year free of alcohol problems.

Abstinence is required, with normalised blood parameters if relevant.

- Must not drive and must notify the DVLA.

Licence will be refused or revoked in all cases of any history of alcohol dependence  within the past 3 years.

Abstinence is required, with normalised blood parameters if relevant.

For both driving groups:

  • licensing will require satisfactory medical reports from a doctor
  • the DVLA may need to arrange independent medical examination and blood tests
  • referral to and the support of a consultant specialist may be necessary.

Driver and Vehicle Licensing Agency. Drug or alcohol misuse or dependence: assessing fitness to drive. DVLA, 2018.  Available at: www.gov.uk/guidance/drug-or-alcohol-misuse-or-dependence-assessing-fitness-to-drive

Contains public sector information licensed under the Open Government Licence v3.0 (www.nationalarchives.gov.uk/doc/open-government-licence/version/3/)

9. Be firm but caring with patients presenting in crisis

Crises are common because dependent drinkers, especially those with a long history, have often wrecked their social networks and exasperated those who are closest to them. At the risk of generalising, it is important to maintain a firm but caring approach.

Don’t see the patient there and then if they are clearly intoxicated (see also tip 8 regarding fitness to drive if they have driven to the surgery). The important thing is to recognise this before the patient gets into the consultation room, otherwise you risk a long battle trying to extract them. Try lines like: ‘I’d really like to see you, but that can’t happen today because you’ve had too much to drink. Let’s make you another appointment.’ This doesn’t break confidentiality because their behaviour is already in the public domain.

A breathalyser can be really useful here (as mentioned in tip 2) but if there are any obvious speech or motor signs of intoxication it is not necessary. The same principle applies to telephone consultations, although it can be difficult to safety net the calls when self-harm or suicide are threatened. Often it is worth giving simple, firm advice to a third person who may be present, but if not, give simple harm-reduction advice and offer to see them when they are sober.

One mental health scenario that is a potential emergency is when a patient has suddenly stopped drinking within the last 2–3 days and presents with a symptoms of (even mild) confusion or delirium that is new but with no evidence of recent drinking. They must be urgently assessed at hospital as they may have incipient Wernicke’s encephalopathy or onset of a delirium tremens, both of which have a high mortality rate if untreated. If necessary, they may need to be admitted against their will under common law or the mental capacity act.

10. Signpost support services, including those for carers and relatives

Apart from national helplines and agencies such as Alcoholics Anonymous (AA), the services available will be different in each locality. Find out what services are available in your area, for example, the meeting times and places of the local AA group, and have the details to hand to share with patients. Make sure you also have leaflets that clearly describe how someone can self-refer to the local alcohol service.

Sick notes are a common request from people who misuse alcohol. Consider linking any sick notes to getting help—you can vary the length of time given based on whether or not they have engaged with the specialist alcohol service.

It is also important to signpost information about the resources and support available for the relatives/carers of dependent drinkers. A selection of resources for people with drug and alcohol problems and their relatives/carers are listed in Box 1.

Dr Stephen Willott

GP and Clinical Lead for Alcohol and Drug Misuse, NHS Nottingham City

Box 1: Resources for people with drug and alcohol problems and their relatives/carers

Addiction Helper

Free help for anyone affected by addiction with advice on both NHS and private drug and alcohol treatment options

Al-Anon

Self-help support organisation for families and friends of people with alcohol problems

Alcoholics Anonymous

Self-help organisation for people dependent on alcohol

Alcohol Focus Scotland

General alcohol advice and help finding services in Scotland

Alcohol Change

Charity formed from the merger of Alcohol Concern and Alcohol Research UK. 

Counselling Directory

Free and confidential service encouraging those in distress to seek help

Down Your Drink

Online programme for people wishing to reduce their alcohol intake

Drinkline

General alcohol advice and help finding relevant services in England and Wales

  • Telephone: 0800 917 8282

Drink and Drugs News residential directory

Directory of residential services offering treatment for alcohol and drug dependence

Federation of Drug and Alcohol Practitioners (FDAP)

A professional body for the substance use field that aims to help improve standards of practice across the sector.

NICE information for the public on alcohol-use disorders

This information explains the advice about treating harmful drinking and alcohol dependence that is set out in NICE clinical guideline 115

Talk to Frank

General drugs advice and help finding drug and alcohol services throughout the UK, plus an online directory of services

Wales Drug and Alcohol helpline (DAN 24/7)

General drugs advice and help finding drug and alcohol services throughout Wales

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