SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Post-its from Practice:
Make no assumptions, thanks for medical students and don't forget to check everyone's alcohol! (Jul 2006)

Every few weeks, a group of medical students come to our practice. They come with a range of experience and knowledge, depending on their seniority, and are often surprised how exciting and varied general practice is. One previous group were especially keen and asked to go out on a home visit.

That day, I had a request to visit an 85 year old Asian woman who had fallen again. Several doctors had visited her for similar episodes and so far, no cause had been found. So I phoned the patient and obtained her permission for the students to go ahead of me and make their assessment first.

After about 30 minutes, I went round to discuss the student's findings. They presented them rather well and rounded up their summary with a question: did I think it was relevant that she was drinking half a bottle of brandy per day?! Now nobody previously had recorded her alcohol intake, maybe because we had assumed that Asian octogenarians don't drink! Yet the patient had been drinking this amount for years and didn't think it was a problem.

Excessive alcohol is so often the condition patients don't think to mention and doctors don't want to discover. It is not only harmful to the liver, but also increases the risk of coronary heart disease, hypertension, diabetes, obesity, depression and other psychiatric illness, and is associated with gastric symptoms, accidental injuries and domestic violence - the list seems endless.

It is estimated that about 25% of consultations are directly related to alcohol and a further 25% indirectly related. Putting this another way, 20% of patients that consult their GP are excessive drinkers which means that the average GP see 360 patients each year who are misusing alcohol - or approximately seven patients every week. Yet 60% of GPs only intervene with seven or fewer of these patients per year! Putting it more globally, a conservative estimate suggests we "fail to diagnose and fail to treat" about six million people.

Many if not most of these excessive drinkers are unlikely to seek help for their drinking, and on the whole they do not actually need treatment as such. What they do need is early identification and early intervention, based on proven clinical techniques. Clearly our baseline practice needs to be improved, with minimum standards of screening and appropriate guidelines regarding treatment and interventions.

This elderly patient had long gone past the excessive drinking stage and was dependent. She did extremely well with a home detoxification, and has not drunk since. Her diabetes and hypertension are easier to control and, so far, she has had no further visits for falls.

So don't forget to ask everyone you meet about alcohol, wherever you work. Make no assumptions - you will often be wrong. And welcome those medical students in - they can be a blessing!!

- Dr Chris Ford