With the toll that excess alcohol takes in terms of personal misery and the national purse (>1600 million/yr in the UK), the need to reduce alcohol intake should rank as one of the leading aims of preventive care. The reason why alcohol is not at the top of the agenda is not just that doctors are so fond of it (the profession has three times the national rate of cirrhosis), but because there is a powerful and pervasive lobby which ensures that alcohol is cheaper (in relative terms) and more readily available than ever before so that its use on an individually moderate scale arouses no comment. It is assumed to be safe, provided one is not actually an alcoholic. However, it is more helpful to view alcohol risks and benefits as a spectrum. A strategy to reduce the bad effects of alcohol in your patients might comprise:
- If a symptom could be alcohol-related, ask in detail about consumption.
- Question any patient with alerting factors accidents, driving offences, child neglect, assault, attempted suicide, depression, obesity. Question others as they register, consult, or attend for any health check.
Helping people to cut down
Time interventions for when motivation is maximal, eg as (or before) pregnancy starts. Small reductions do matter.80
- Take more non-alcoholic drinks; reduce the sip frequency, eg by shadowing a slow drinker in the group. Don't pick up your glass until he does (and don't hold your glass for long: put it down to avoid unconscious sipping).
- Limit your drinking to social occasions and learn to sip, not gulp.
- Don't buy yourself a drink when it is your turn to buy a drinks round.
- Go out to the pub later (may not work as some UK pubs, since 2005, are licensed, to be open all night). Take days of rest when no alcohol is used.
- Learn graceful ways of refusing: No more for me please, I expect I'll have to drive Jack home or I'm seeing what it's like to cut down.
Maintaining reduced drinking
- Agree goals with the patient.
- Suggest he keeps an alcohol diary in which he records all drinking.
- Teach him to estimate his alcohol intake (u/week, see below).
- Consider an Alcohol Card in the notes to show: units/week; pattern of drinking; reasons for misuse; each alcohol-related problem (and whether a solution has been agreed and action implemented); job record; family events; biochemical markers (GGT, MCV); weight.
- Give feedback about how he is doing eg if GGT (γ-glutamyl transpeptidase) falls are discussed at feedback, there is much lower mortality, morbidity and hospitalization compared with randomized control subjects.
- Enlist family support; agree a system of rewards for sobriety.
- Group therapy, self-help groups, disulfiram, local councils on alcohol, community alcohol teams and treatment units may also help.
Setting limits for low-risk drinking
eg 20U/week if ‚; 14U/week if there are no absolutes: risk is a continuum. NB: higher limits are proposed, on scant evidence (eg 4U/day; 3U for women). One unit is 9g ethanol, ie 1 measure of spirits, 1 glass of wine, or half a pint of ordinary-strength beer.81 Primary care is a good setting for prevention: intervention leads to less alcohol consumption by ~15%, reducing the proportion of heavy drinkers by 20% at one-twentieth the cost of specialist services. There is no evidence that GP intervention has to include more time-consuming advice such as compressed cognitive/behavioural strategies. Simple advice works fine as judged by falling GGT levels at least for men. After interventions, women may report drinking less, but this is not reflected in a falling GTT.
Does education work?
A bit: as medical students, we drink less in the final year, compared with year 2; but, overall, 27% are problem drinkers. Should we all write and implement a personal alcohol policy?
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