TIME FOR A DRIER JANUARY?Rob Walker - 10 Jan, 2018
Andy is 36, is usually fit and well and you rarely see him. But he’s come in because he’s struggling to sleep and is asking if he can have a few sleeping tablets ‘just to re-set things’. He says he gets to sleep fine, but wakes often and does not feel like he has much restful sleep and feels groggy in the morning. His mood seems low and he says he’s had some arguments with his wife over Christmas. It quickly becomes clear that his alcohol intake is likely to be the major problem. He had always drunk quite heavily at the weekend, getting through at least 2 bottles of wine, but his weekly drinking has steadily increased to the point where he rarely has a night without alcohol and often drinks 2-3 glasses of wine or beer per night. He has now got into a vicious cycle of having an increasingly large night-cap as well to try to help him sleep. It’s always difficult to estimate home measures, but he is drinking 40+ units/week. He has no symptoms that suggest dependence.
We know alcohol related illness is a major issue for the health service. The latest NHS statistics (for 2015/16) show that 1.4% of all deaths in the UK were due to alcohol, similar to the previous year, but still an increase of 10% since 2005. The number of hospital admissions directly attributable to alcohol was 2.1%, an increase of 3% from the previous year and an increase of 22% since 2005. One measure suggested by NICE in 2010 (https://www.nice.org.uk/guidance/ph24) was that GPs (as well as a broad range of other health and non-health professionals) should screen for, and offer, brief interventions for risky alcohol consumption. A systematic review in 2016 (http://bmjopen.bmj.com/content/6/8/e011473) suggested that alcohol brief interventions (ABIs) can play a small but significant role in reducing alcohol consumption. However, an article in the BMJ in 2017 (http://www.bmj.com/content/356/bmj.j116?variant=full-text&sso=) questions both the evidence and practicalities for implementing ABIs in General Practice - they point out that ~90% of patients that drink too much alcohol also have either a poor diet, do too little exercise or smoke; should we use our limited time to prioritise ABIs over other lifestyle interventions, especially when it is recommended ABIs should take 5-15 minutes?
Whether or not alcohol screening and intervention is feasible or effective in primary care at a broader level, it is clear Andy needs help with his drinking. So what options have we got to help him? It certainly would be sensible to do a screening questionnaire as recommended by NICE e.g. AUDIT (https://www.alcohollearningcentre.org.uk/Topics/Latest/AUDIT-Alcohol-Use-Disorders-Identification-Test/) on which he scored 14, putting him in the ‘increasing risk’ category but close to ‘higher risk’. He’s got pretty good insight into the fact that he is drinking too much and that it is probably impacting both his health and his relationships. One option at this stage might be to sign-post him to some self help resources and offer him a review appointment to see how he is getting on. There is an excellent NHS leaflet which, among other things, explains the AUDIT score and promotes a ‘booze tracker app’ (https://www.alcohollearningcentre.org.uk/Topics/Latest/Identification-and-Brief-Advice-Tool-2017-revised-April-2017/) which you can give to him, and I would highly recommend the ‘drinkaware’ website which has got some very good practical advice for cutting down on alcohol (https://www.drinkaware.co.uk/advice/how-to-reduce-your-drinking/how-to-cut-down/).
Another option would be to bring him back for a session of brief structured advice, as recommended by NICE. It is recommended this should take 5-15 minutes and should be based on the FRAMES model:
Give feedback on the risks and negative consequences of alcohol use. Seek the client's reaction and listen.
Emphasize that the individual is responsible for making his/her own decision about his/her alcohol use.
Give straightforward advice on modifying alcohol use.
Menu of options:
Give menus of options to choose from, fostering the client’s involvement in decision-making.
Be empathic, respectful, and non-judgmental.
Express optimism that the individual can modify his or her alcohol use if they choose.
I hope those few pointers will give you some tools for tackling excess alcohol consumption, and if you want further training, options for e-learning courses on alcohol identification and brief advice (IBA) can be found here: https://www.alcohollearningcentre.org.uk/eLearning/IBA/alcohol-iba-in-primary-care-e-learning-course/