Issue 34.
Managing heavy drinkers in general
practice
The Drugs and Therapeutics
Bulleting recently had a useful piece on this subject.
Estimates suggest that over 9
million adults in Britain drink alcohol at levels that could endanger their
long-term health. Each year, in England and Wales, around 28,000 die prematurely
from physical diseases, accidents and suicides related to alcohol use.
During 1996, 27% of men in
Britain were drinking more than 21 units of alcohol per week, and 14% of women
more than 14 units per week - that is, at levels considered potentially harmful
to health. Among men and women aged 16-24 years, 35% and 22%, respectively,
exceeded these amounts.
There are many barriers to the
recognition of heavy drinking in primary care. GPs may be inhibited by a lack of
confidence in their ability to deal with the problem, or they may believe that
treatment is pointless and that the patient will be unable to change their
drinking habits or co-operate with treatment.
New-patient checks, and health
promotion and blood pressure clinics, provide opportunities for routinely
recording the quantity and frequency of alcohol consumption. In a busy surgery,
simple screening questionnaires can provide further points to excessive
drinking. For example, the CAGE questionnaire involves just four questions:
Have you ever felt you ought to Cut
down on your drinking?
Have people Annoyed you by
criticising your drinking?
Have you ever felt bad or Guilty
about your drinking?
Have you ever had a drink first
thing in the morning to steady your nerves or get rid of hangover (‘Eye
opener’).
A brief intervention comprises an
assessment of alcohol intake, provision of information on hazardous or harmful
drinking, and clear advice for the individual to cut down or stop drinking. The
intervention centres around a single patient contact, although with the option
of further appointments.
Brief interventions may simply
involve advice plus a leaflet, or (more effectively) can include provision of
self-help manuals, advice about local or national support services, feedback of
blood test results, level of personal risk and how the individual’s drinking
compares with that of the general population, or some form of condensed
counselling.
Several large randomised
controlled trials, show that brief interventions will often reduce alcohol
consumption and the proportion of patients drinking at hazardous levels. An
overview of seven such trials, found that alcohol consumption fell overall by
24% (95% of CI 18-31%) in participants receiving brief intervention when
compared to control patients who simply underwent assessment.
Overall the primary healthcare team has an important role
in encouraging and enabling the heavy drinker to change, but to achieve this
they may need more training and specialist support than is presently available.
A high degree of alertness is needed to the wide variety of ways in which
problems related to alcohol can
present in routine care. The use
of simple screening questionnaires can help to identify hazardous and harmful
drinkers, a significant proportion of whom may be persuaded to cut down to safer
levels if given clear advice and education on the harm their drinking could
cause or is causing.
Others will require a more
prolonged and goal-directed intervention over may consultations, often in
collaboration with specialist services. Those who have developed dependence on
alcohol but who are committed to stopping drinking may require assisted
withdrawal (detoxification), which in many instances can be carried out at home,
provided there is adequate support. A long-term perspective is needed because
alcohol dependence is a relapsing disorder, but results can be rewarding. The GP’s
knowledge of the patient and the family makes him or her a crucial link in the
network of medical, psychological and social support that each will need.
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Herbal medicines: where
is the evidence?
Sales of herbal medicines are booming. This is particularly
true in the United States, where the market for herbal supplements is now
approaching $4bn a year. The fastest growth has been recorded for St John’s
wort, a herbal antidepressant whose sales increased in one year by 2800%. Faced
with such figures doctors are inclined to ask where the evidence is. Are there
rigorous trials to show that herbal treatments work?
An increasing body of evidence is now emerging from
systematic reviews and meta-analyses of randomised clinical trials. These
suggest that some herbal medicines are efficacious. The increased demand for St
John’s Wort, for instance, was triggered by press reports of a meta-analysis
of 23 randomised trials of 1757 patients with mild or moderate depression. The
authors concluded that extracts of Hypericum were significantly more effective
than placebo (odds ration 2.67; 95% confidence interval 1.78 to 4.01) and as
effective as conventional antidepressants (odds ratio 1.10; 93 to 1.31) in
alleviating the symptoms of mild to moderate depression. Since this article was
published, at least nine further randomised trials have appeared, all of which
confirm the efficacy of this herbal antidepressant.
Systematic analyses of other herbal medicines followed and
drew similarly placebo controlled, double blind randomised trials of ginkgo biloba for dementia, covering 1497 patients, showed that ginkgo was more
effective than placebo in delaying the clinical course of dementia
In all, about 40 systematic reviews or meta-analyses of
herbal drugs are available today (a full list provided by the author is
available on the BMJ’s website).
Even though herbal remedies may be effective, do their
benefits outweigh the risks? Most herbal remedies in the United Kingdom and
United States are sold as food supplements. Thus they evade regulation of their
quality and positive conclusions.
The UK’s minister for public health recently pointed out
that the regime for unlicensed medicines does not give systematic protection to
the public against low quality and unsafe unlicensed herbal remedies. Two recent
British cases of severe nephropathy caused by Chinese herbal tea administered to
treat eczema” illustrate this.
Huge variations exist in the quality of herbal medicinal
Doctors also have to realise that detailed questions about use of herbal drugs
form part of taking a medical history. Finally, doctors should monitor the
perceived benefits and adverse effects of self prescribed herbal treatments
consumed by their patients.
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