SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Post-its from Practice:
The challenge of change (Nov 2011)

I had to compose myself as Craig shut the door behind him after his appointment. I had just told him that, as we knew, his liver function had deteriorated and his protein was alarmingly low. He already knew he had cirrhosis (scarring of the liver) and ascites (fluid retention in the abdominal cavity) and we had discussed many times the significance of these.

Craig at 42 years had been a patient of ours for about 3 years. He had started drinking seriously at the age of about 12, not long after he had returned to live with his mother and her new partner, after having been in care for 3 years. His mother married and quickly had 2 children with this man, who also adopted Craig. Craig's father was an alcoholic and had left the family home shortly after Craig's birth. Craig remembers being excited about becoming a member of a "real" family, but this feeling didn't last. His step-father soon began to verbally and physically abuse him and Craig rapidly became a frightened broken adolescent. He had told me how he felt on picking up alcohol. He described how he felt whole again. He spent the next 8 years in an alcohol haze and never once received any help or no one even expressed concern about his drinking. He frequently got arrested which reinforced his step-father's image of him as a waster and a "no-good".

Craig branched out to heroin, cocaine, speed and almost any drug he could get his hands on but always came back to his first love, alcohol. He tried treatment but was often discharged because of his alcohol use or his anger and went into rehab a couple of times but relapsed immediately. When I first met him I remember him saying it was only when he was drinking that he felt in any way human. He hated his feelings post detox, even after counseling and groups, but he was most concerned about his anger, which became explosive when he was sober. He said he had relapsed to get rid of all the hurt and anger.

When he first came into treatment with us, Craig said he wanted to try again. In the early days he stabilized well on 80mls of methadone and tried to reduce his drinking to one bottle of vodka (30 units), from at least 2 bottles per day. He tried so hard it almost hurt. He even requested to see a forensic psychiatrist but we can only refer through the local psychiatrist and this meeting is perhaps best forgotten. The psychiatrist suggested Craig "pull his socks up" and stop drinking, having absolutely no understanding of dual diagnosis.

Eventually Craig told me that he had decided to carry on drinking. He totally understood the consequences and he knew he would die. I had explained to him the stages of liver disease, starting with fatty liver, which is the commonest and mildest form of liver damage and reversible; moving on to fibrosis, which is scar tissue that represents the liver's response to injury and finally cirrhosis. The early symptoms of liver disease can be non-specific and can include fatigue, vomiting, diarrhoea and abdominal pains. As liver damage increases, liver failure begins to develop and may lead to liver cancer. The risk of liver cancer is greatly increased once cirrhosis develops and cirrhosis should be considered to be a pre-malignant condition.

The prognosis of cirrhosis partly depends on whether patients stop or continue to drink. People with early cirrhosis and who stop drinking, have an 80% chance of being alive after 10 years and those like Craig, with symptoms and who continue to drink will die within three years.

And Craig is not alone. Deaths from liver disease in the UK are rising at an alarming rate while the rate of all other major causes of death, including heart disease are reducing. Plus people are dying younger from it and the average age of death is 59 but I fear Craig is not going to reach even his 45 year.

I wish I could "cure" Craig, but know I can't. All I can do is continue to care and support him - and never give up on him. To quote Martin Luther King "Change doesn't roll in on the wheels of inevitability but comes through continuous struggle".

- Dr Chris Ford
GP Lonsdale Medical Centre, Clinical Director for IDHDP, and a Member of the Board of SMMGP

See the Network 33 - Liver Special Edition (November 2011).