SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Post-its from Practice:
Chris getting cross can be constructive! (Nov 2008)

Sitting before me yesterday was Mark, who was really pleased with himself as he had now completed 5 weeks with no alcohol. Mark is only 32 years old but already has severe medical problems, including chronic pancreatitis and liver damage resulting from his 14 years of dependent drinking. Five weeks is the longest time he had been alcohol free in those 14 years and as from yesterday he hopes to continue to be alcohol free one day at a time.

He has been a patient of the practice for about two years, coming back to live with his mother after his wife threw him out because of his drinking. In those two years he had not seen his two daughters now aged 3 and 4 years. His mother in her late 70s welcomed the company and in the beginning enabled his drinking. The transfer letter from Mark's previous GP was helpful and asked us to continue his diazepam prescription. However it added that he had despaired with his drinking as he had had endless detoxifications, both in-patient and out-patient yet he had never managed to stay off drink for more than one day.

I remember the first time Mark came to see me 2 years ago. As his mother, a complete teetotaler, was a patient of mine she had asked me to see him. I admit he nearly drove me to drink the first time (and many times since!) I met him. If left he can talk for hours telling complicated stories about nothing when you ask him a simple question like "what have you drunk today?"!

During the past two years he has had endless "emergency" detoxifications, usually on acute medical wards during admissions for one of his medical problems. But at his request we have been able to arrange two in-patient detoxifications in our local specialist detox unit. Both times he went in with great promise, received support but declined rehabilitation and relapsed on discharge. We have also undertaken three community detoxes and again he drank immediately on completion. But were all these episodes a waste of time and resources? I think not. One of the many papers we have written over the years, which has not been published, was how lessons are always learnt from a drugs or alcohol detoxification, whether completed or not. Also fashion trends, evidence and opinion vary over time as to whether frequent detoxifications from alcohol help or damage the brain.

During Mark's last medical admission about 2 months ago he was again told if he did not stop drinking he would be dead before he was forty. He came saying he wanted to have another go at community detoxification and proceeded to list the reasons why the previous ones had failed. I said I would discuss it with the team and that he should present at 3pm the next day after the team meeting. We discussed it and agreed that if we didn't try again then death was going to be the inevitable outcome. So he did come back but he was more drunk than I had ever seen him before. As he stumbled into my room he denied it and rambled on about everything and nothing. I was so cross I broke all therapeutic boundaries telling him he was a waster, a drunk and that I was not coming to his funeral. He looked terrified as I shouted at him to leave the room and not to return until he had decided he wanted to continue living!

A week later, Mel the specialist counselor entered my room with a large envelope containing a beautiful thank you card and a lovely pink (my favourite colour) cyclamen from Mark. Mel informed me that Mark wanted to say thank you and say that he was now ready to try and save his life, but that he was too frightened to come back in my room in case I shouted at him again. When he did, he told me that he had really heard me this time and even though he was drunk he could see that I was really worried about him.

Of the 39% of men & 23% of women drinking above safe levels in the UK, 5% of the population like Mark are dependent. A detoxification is only needed in someone who has developed a state of alcohol dependency which is manifest by symptoms of alcohol withdrawal e.g. sweats, sleep problems, anxiety. They cannot usually manage 24 hours without a drink. The drug of choice is usually chlordiazepoxide (Librium) although diazepam can be used as an alternative.

Occasionally people make community detoxification too restricted and complicated but the main points for a community detoxification is to be flexible. There needs to be some titration against the amount of alcohol the patient is using and the severity of the withdrawals they are experiencing. The regime needs to fit to individual need and symptoms. It is important to discuss the procedure with the patient and carer and it is helpful if the carer can give out the medication on a daily basis. If that's impossible we get the patient to attend daily and give out the medication. Plus don't forget to treat any nutritional/vitamin deficiency and commence thiamine 100mg daily for two weeks.

Since that day Mark has not drunk any alcohol. Already, Mark has improved physically and with counseling twice a week he is beginning to work on his mental well-being.

It may be that now is the right time for him, or that he is using all the lessons learnt from previous attempts, or that his mother has changed (thanks to Al-ANON), or maybe that he saw his GP lose her rag. Most likely it is a combination of all of these, but whilst it may still be early days, there is definitely something different about things this time.

- Dr Chris Ford