SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Post-its from Practice:
We have to keep trying to effect change (Feb 2013)

One of the privileges of being a GP is the opportunity to follow through the "cradle to grave" ethos that the NHS was founded on. Sadly this does mean that sometimes we are caring for people whose lives end prematurely.

Gary was registered with the practice before I joined 22 years ago and I knew him as a young man with a young family and only occasionally saw him when one of the children was ill. It was in his late 20's that his drinking first raised itself as an issue. He was convicted of a drink driving offence and as a condition of getting his licence back he had been told to see us for help. He was a typical binge drinker often having several days without alcohol but when funds were available he would drink heavily at weekends.

Little happened for 5 years but then he reappeared, ostensibly in an effort to preserve his marriage which was by now being affected by his daily heavy drinking. Blood tests revealed mildly abnormal liver function but he declined a referral to support services, as he was sure he could "sort himself out".

He divorced, a new relationship came and went, he lost his job, and then another; eventually he came to see me, the alcohol and a poor diet had taken its toll. He was underweight, unkempt and slightly jaundiced. This time his liver function was severely deranged but he had insight into his situation and agreed to be referred to the specialist alcohol service.

Gary successfully completed a medically assisted withdrawal but despite encouragement to engage with mutual aid he found the prospect of a lifetime of abstinence too difficult to deal with and resumed drinking. Now the pattern became one of acute hospital admissions, cessation of drinking in hospital and then resumption soon after discharge. His cirrhosis progressed to decompensated liver disease and just before Christmas last year he was admitted for the last time. He died aged 43 from complications of his alcohol related liver disease.

We have a practice policy of reviewing all deaths and on going through his notes I wondered if at any of the times we had seen him in the past before he became dependent we may have been able to influence him to change his behaviour.

It is difficult for many of us to understand how in the face of irrefutable evidence of the harm being caused, that some people fail to change their behaviour, and yet this shouldn't prevent us from trying to effect this change. I was somewhat taken aback by some of the responses to the recently published Screening and Intervention Programme for Sensible drinking (SIPS) study which some have chosen to interpret as suggesting that a few minutes asking about alcohol use and then providing a leaflet is all a GP needs to do.

I am not questioning the evidence as this may well apply across a large section of the population, however in General Practice we work with individuals and it is our duty to deliver the best possible care to each patient we see. If we do this then we contribute to the wider Public Health picture.

Gary's death at such a young age is a tragedy. For me it reinforces the need to ask all my patients about their alcohol use more often and in more detail, to support those at risk and offer help and support. Unfortunately we never really know when our interventions do prevent adverse outcomes happening, but seeing the results of the times they don't, keeps me trying.

- Dr Steve Brinksman
Birmingham GP, SMMGP Clinical Director, RCGP Regional Lead in Substance Misuse for the West Midlands