Alcohol Addiction
Approaching the problem drinker: Part One
- ALCOHOL - THE INTERVIEWS
This programme reviews classification, clinical features and the psychological, social and physical aspects.
Twenty-five per cent of hospital admissions are Alcohol related. An average general practitioner list will contain 135 heavy drinkers, forty problem drinkers and seven alcohol dependent patients. Alcohol remains behind smoking but ahead of cannabis and other drugs as a public health issue.
There has been a move away from seeing the problem as “Alcoholism” and is now better seen as a risk factor for ill-health.
In the past there have been attempts at categorisation. For example, the Jellinek typology which describes types of drinking behaviour but does not include other important dimensions of the problem. The Alcohol Dependence Syndrome offers an alternative and includes the following features: Narrowing of drinking repertoire, Increased salience, Tolerance, Withdrawal symptoms, Relief drinking, Compulsion to drink and Rapid reinstatement of dependence (after a break).
The programme continues with some clinical examples. Try to identify the features which have lead to them having a problem with alcohol and the reasons why they sought help.
Most patients have mixed feeling about their drinking, and the damage it is causing them and others. Many may not even recognise that alcohol is a problem and will present with depression, anxiety or marital difficulties. The reverse can also be true. For example, a bereaved person may turn to drink. Problems at work can cause or be caused by excessive drinking.
As a good rule of thumb, one drink-driving offence may conceivably be “bad luck” and poor social judgement but a history of two convictions is a consequence of an alcohol problem.
Alcohol Addiction
Approaching the problem drinker: Part Two
- ALCOHOL - APPROACHING THE PROBLEM DRINKER
Asking about alcohol consumptions is a simple, import and frequently neglected activity. Screening questionnaires can be useful, and the CAGE Questionnaire is short and can be a conversation starter. One of the factors affecting treatment can be that taking a history can raise issues for the health professional. Addictions are but one area of sensitivity – is it something to do with yourself or do you fear antagonism from the patient? The skilled clinician has learnt the art of history taking and understands a little of their own counter-transference’s – feeling and personal issues that they bring to the consultation. For example, if one of your parents died of alcoholism it will have an impact on the way you practice and your relationship with alcoholic patients. The therapeutic relationship is highlighted as warranting particular attention with such patients.
There are many layers of treatment – support, practical advice and guidance as well as the development of an inner understanding. Simply discussing the subject can have a considerable impact. “We are not about curing people, we are about helping people change. Let’s try and achieve a little and for some patients that is a lot”. Thus stage one (precontemplation), getting them to think about their drinking, would constitute a successful conclusion to a consultation. Stages of change is a useful model to frame your treatment plan.
The severely dependent and those with additional psychological, social or physical problems benefit from an initial stay in hospital. The impact of simply providing asylum should not be neglected. In-patient programmes are usually based on educational material and identification with other group members. Planning for after-care is a critical part of the treatment. Self help groups can be a considerable source of help, the best being non-judgmental, non-authoritarian and organised by the real experts – other patients.
Alcohol Addiction
Approaching the problem drinker: Part Three
- ALCOHOL - APPROACHING THE PROBLEM DRINKER PART THREE
Primary prevention is the process by which the numbers of those requiring help is kept to a minimum. The advice about how many units of alcohol that is safe continues to go down with the recommendation that any is bad for you, but just how bad? None in pregnancy and less than 14 (maybe 8) units per week is the current pragmatic approach.
This short video does not provide a comprehensive discourse on the subject but an essay that discussed the role of price, education and social attitudes would cover most the the pertinent facts and get you a pass mark.
Finally:
- Ask each patient about alcohol consumption. It is a useful habit and you will get an idea about the so-called normal range, recognising how difficult it is to get an accurate drinking history , and that in itself is worth knowing. Can a week go by without them having a drink is a useful screening question, as long as it doesn’t disguise the massive binge session “enjoyed” every couple of weeks.
- Don’t give up, there is no such thing as a hopeless case. (Would you challenge that assertion and why – discuss.)
- There are few things more rewarding than seeing a patient getting to grips with their problem drinking. The benefits to the family and children are profound.
Detox
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