Paying the price

As the annual cost to the NHS of alcohol abuse hits £3.5billion, GPST editor Dr Peter Livingstone offers his perspective on the impact on primary care 

MOST people drink alcohol in this country, whether it’s a glass of sherry at Christmas or a few pints at weekends.

There is nothing wrong with moderate drinking and research published in the BMJ last year even suggested that small amounts of alcohol can reduce your risk of developing cardiovascular disease.

However, problems begin when alcohol is consumed in large amounts as this can have a major detrimental effect on a person’s health, not to mention the wider social impact. Recent figures from the Department of Health show the total cost to the NHS of alcohol abuse has reached £3.5 billion, a rise of 30 per cent in just three years. And a report from the NHS Information Centre showed that, in 2010, alcohol dependency cost the NHS £2.4million in prescription items.

Where I work in the west of Scotland at least half the patients in my morning surgery will have alcohol-related problems. Contrary to what many people may think, those at greatest risk of harm are the non-dependent drinkers. These are people consuming more than the recommended weekly alcohol intake (21 units for men, 14 for women) but who are not classed as ‘alcoholics’. And while some may seek help for alcohol-related health problems, others may not yet have reached that stage.

For this reason, I think screening and brief interventions in primary care are a good idea as they can identify drinkers and reduce potential complications. In March, a committee of MPs sparked debate by recommending GPs routinely question patients about their drinking. But while a policy of blanket screening is not necessarily the best way forward, there is a place for GPs to use their judgment and question patients where appropriate.

I recently saw a gentleman who presented with dyspnoea and palpitations. He was worried that it was his heart and thought that stress at work was the cause and denied any use of alcohol or illicit substances. He was admitted to hospital with an irregular tachycardia and treated for atrial fibrillation.

Sometime later in clinic he was disgruntled that the hospital had told him that his recent admission was a result of excessive alcohol consumption. I was shocked as he had always denied any alcohol consumption but it turned out that marital problems had led him to drink heavily over the previous year.

Eventually, he had insight into his excessive drinking and was referred to the community addiction team. He attended Alcoholics Anonymous and has been alcohol-free for six months.

Another patient I treated recently at an afternoon clinic made me realise how alcohol not only affects a person’s physical wellbeing but also has psychological and social impacts. This patient was a successful businessman who presented to hospital with pancreatitis secondary to alcohol consumption. Exploring his alcohol intake he admitted to drinking at least a bottle of vodka per day but didn’t accept he had a problem. He continued to drive and maintain a job and neither his wife nor work colleagues had expressed concerns regarding his alcohol intake.

I urged him to stop driving while he was drinking but he dismissed my concerns. It put me in a very tricky ethical dilemma and I told him during one of our consultations that I was duty-bound to inform the authorities if he continued to drive under the influence. He became angry and aggressive and stormed out, I suspect, still intoxicated. Following discussions with my GP colleagues and with an MDDUS adviser, I wrote to tell him that I’d have no choice but to inform the DVLA if he continued to drive because he posed a major risk to the public.

It was a very difficult decision to breach patient confidentiality but I eventually informed the DVLA and he subsequently lost his licence and then his job. I felt anxious and disheartened but he gave me no other option. We all have to make decisions in general practice, however some are easier than others.

Amongst the patients I treat for alcohol-related problems are a particularly challenging group familiar to most GPs. They are the ones who regularly promise you the world if only you would give them some chlordiazepoxide to help them abstain from alcohol. They come in week after week promising you they will abstain – despite being intoxicated – and engage with addiction services if you will prescribe medication or help them get their housing benefit.

The road to abstinence is paved with good intentions and I think it is important to be positive with each patient who wishes to give up alcohol. However, we need to remember that patients must take responsibility for their alcohol consumption and, despite our best efforts, some may never refrain from drinking. A difficult fact for any doctor to accept.

So while alcohol in moderation has been shown to be good for you, when it becomes a “crutch” or a way of escaping from reality, problems will occur. And it can be a fine line between the two states. Remember, as Dylan Thomas once wrote: “An alcoholic is someone you don’t like who drinks as much as you do!”

Dr Peter Livingstone is a GP locum and editor of GPST