Specialty alcohol clinical settings are an important focus of this book and are obviously an appropriate location in which to pursue the treatment of drinking problems. But individuals with drinking problems – sometimes identified, sometimes not – are scattered across a range of health and social service settings, typically in far larger numbers than are present in a nation’s specialty alcohol care sector. This chapter describes screening procedures that can identify such cases, presents interventions that can be applied in even short-term clinical contacts outside the specialty sector, and provides guidelines for determining when care collaboration with specialty services is called for.
To the probation officer, school counselor, or primary care nurse, worrying about drinking problems may seem a distraction from their “day job.” What good does it do for nonspecialists to get involved in the treatment of drinking problems, and, in any event, isn’t that someone else’s responsibility? Such attitudes are short-sighted for at least three reasons.
First, many interventions directed at problems other than drinking in nonspecialty settings fail precisely because of an unrecognized drinking problem. Alcohol misuse is a causal or exacerbating factor in countless problems that come to the attention of health and social service professionals: unhappy marriages, family violence, unemployment, anxiety disorders, injuries, school failure, and cardiovascular illness, to name but a few (see Section 1). When the drinking problem is not addressed, the attempts to tackle the presenting problem may be ineffective or even cause harm. The “depression” will not respond to the prescribed antidepressant, a peptic ulcer will fail to heal, a distressed marriage will rapidly deteriorate, leaving the helping professional puzzled and frustrated. Thus, rather than being a distraction from the main clinical goals of nonspecialist clinicians, tackling drinking problems can facilitate the achievement of those goals.
Second, nonspecialist settings provide the chance to influence low-level drinking problems before they become serious. Specialist alcohol services in most countries tend to serve individuals with quite severe drinking problems (Humphreys & Tucker, 2002). In many cases, this end state could have been forestalled by intervention earlier in the life course. A serious discussion with a guidance counsellor when college drinking has just started to harm academic performance, advice to cut down from a physician at the first report of occasional tiredness after an evening’s drinking, support from an employee assistance programme after a few late arrivals to work on Monday mornings may only nudge the life course slightly. But even a small intervention made early enough can have a pronounced long-term impact, akin to how a small turn of an ocean liner’s wheel as it leaves Boston Harbour can make it arrive in Liverpool rather than Brest.
Third, nonspecialist settings can be the bridge to specialty care for individuals with severe but as yet undetected drinking problems. Not all drinking problems can be managed by nonspecialists, making specialty treatment desirable. Yet because of stigma, lack of information, or ambivalence about change, even the most severely impaired drinkers may hesitate to directly access a designated alcohol treatment programme. With proper screening and referral, however, the office of a trusted GP or employee assistance programme staff member can be the entry route to potentially life-saving care for a greatly troubled individual.
Nonspecialist settings in which drinking problems are prevalent
Table 9.1 lists settings in which drinking problems are prevalent, if not necessarily recognized. We include on the list the special case of general psychiatry services in which drinking problems are overlooked despite the capacity to treat them. Each setting is described in more detail in the next sections.
Although many people believe that illegal drugs drive most crime and incarceration, no drug competes with alcohol in these respects. Domestic violence, reckless driving, and child abuse are just three of many crimes strongly associated with excessive alcohol consumption (see Chapter 4). The criminal justice system is thus de facto among the largest handlers of people with drinking problems. Assessment of the use of alcohol and other drugs is therefore an essential part of any psychiatric consultation in the criminal justice system, including competency assessments, child custody hearings, and evaluations of dangerousness.
The emergence of in-house employee assistance programmes was both a reaction to and an illuminator of the high prevalence of alcohol problems in many companies. Alcohol is the hidden factor behind many cases of absenteeism, job conflicts, and worksite accidents. Workforces with a particularly high prevalence of alcohol problems – and therefore a particular opportunity for intervention – include the military, law enforcement, and the alcohol industry itself.
Educational institutions at all levels are profoundly affected by drinking problems. In primary school, a drinking problem in the family may be the force driving the child who is chronically late, anxious, socially rejected, or physically aggressive. In adolescence and young adulthood, problem drinking by students themselves is frequently commingled with problems of academic achievement and social behaviour. The widespread anxiety about adolescent use of illicit drugs should not overshadow the fact that, in many communities, alcohol is a more pervasive adolescent problem.
Within the healthcare system, the primary care setting is probably the greatest missed opportunity to address drinking problems, which are in some way implicated in perhaps 25 percent of all visits. Yet recognition of drinking problems is often not given priority, and it is even less frequently the subject of intervention.
Another critical opportunity for intervention in the healthcare system is the emergency room (Crawford et al., 2004; Havard, Shakeshaft, & Sanson-Fisher, 2008). A growing body of work has documented that drinking problems are prevalent among individuals injured in a range of accidents including, but not limited to, road traffic accidents. The shock of the injury can provide a “teachable moment” during which long-ignored pleas for attention to drinking are finally heard.
Although every hepatologist is aware that chronic heavy drinking is a leading cause of cirrhosis of the liver, hepatology clinics do not always sufficiently screen nor intervene with drinking problems. This is not merely a matter of detecting cases of severe drinking, but also of advising abstinence for lower level drinkers to whom such consumption can be unusually dangerous (e.g., those with hepatitis C).
A night’s heavy drinking is often behind an unintentional pregnancy, as well as the contraction of a sexually transmitted disease. These risks arise in consensual sexual relationships when condoms or other forms of contraception are forgotten or simply disregarded. They are also prevalent in sexual assaults, for which intoxicated individuals may be targeted by perpetrators. As the prevalence of heavy alcohol consumption among young women has risen, intervention for women in sexual health and obstetric clinics has become more important, not only for the women themselves, but also, in cases of pregnancy, for the developing foetus (see Chapter 5).
One less appreciated effect of the ageing of the Baby Boom generation is a rise in elderly people who have a substance use disorder (Crome et al., 2011). Such problems can be the source of presenting complaints of confusion and poor memory in a geriatrician’s practice or of depression or agitation in a nursing home. Addressing alcohol problems in this population assumes particular importance in those cases where the individual is taking a prescribed medication that interacts with alcohol.
I was in psychoanalysis for depression 3 days a week for 20 years. I killed a pint of bourbon almost every night throughout it, but my analyst never even asked me about my drinking.
There is no point addressing symptoms without getting at their root cause. That’s why I don’t get distracted by how much patients drink. Once their emotional conflict is resolved in therapy, they won’t need to self-medicate their pain any more, and the drinking will stop on its own.
These comments, the first by an elderly psychiatric patient, the second by a young psychiatry resident, illustrate a sad reality in many mental health settings not specifically dedicated to alcohol treatment: despite the presence of trained psychiatrists, psychologists, social workers, and counsellors, drinking problems are often completely ignored. The reasons for the oversight are partly ideological and partly practical.
Freudian theory, which remains influential with many mental health professionals, holds that heavy drinking is not a problem, per se, but a side effect of a psychodynamic conflict. Freud himself conveyed great scepticism about whether alcoholic patients could ever form a therapeutic alliance that would promote change. This combination of dismissing the importance of drinking on the one hand and being nihilistic about the prospects of intervention on the other has been absorbed into much of the mental health field and remains a considerable ideological barrier to intervention in some settings.
At a practical level, training in psychiatry, psychology, and allied fields often devotes little attention to drinking problems, despite their prevalence in psychiatric settings. Many mental health professionals thus feel incompetent to address problem drinking and hence never broach the subject with patients.
More positively, once drinking is recognized and taken seriously, virtually everything that can be done in a specialist alcohol clinic can be accomplished in a general mental health programme. This would include, for example, all the therapeutic processes and tactics described in Chapter 12.
Drinking problems often go undetected in nonspecialist care settings (Cheeta et al., 2008). If the element of drinking is allowed to remain hidden, it will defeat efforts to help the patient, client, student, or employee. This section starts with a review of clinical strategies for enhancing the detection of problem drinking, followed by a review of biological assays and standardized screening questionnaires.
It is useful to have a few disarming questions about drinking problems that can be fed into any assessment in an almost throwaway fashion. The scene is often best set by a casual introductory remark such as, “I always ask everyone about drinking – it can be important to feel that one can talk about one’s drinking without being got at.” This implies that questions in this area are routine rather than the patient being singled out as a special case, and this is coupled with an immediate indication that anything the patient reveals will be sympathetically heard.
One useful disarming question is “When did you have your last drink?” because it cannot be fobbed off with a yes/no answer. “How would you describe your drinking?” has the same virtue. An open-ended invitation to reveal current concerns can also be effective: “Please tell me about any worries you have related to your drinking – you know, any rows, troubles at home, health problems, things of that sort.”
Questions that feel out the possibility of worry or trouble are more likely to provide a way into fruitful dialogue than are mechanistic questions along such lines as, “Do you drink?” The latter type of interrogation does not immediately reach across barriers toward what the patient is feeling and experiencing. It is too readily deflected by a bland answer, such as “Just socially.”
To bear in mind a list of who may be especially at risk is useful, provided the clinician does not become blinkered to the wider truth that drinking problems can affect both sexes and, either directly or indirectly, people of any age and every occupation. With that proviso, an awareness of a particular occupational hazard is then important (see Chapter 3). The separated, or divorced person; those considered to be at risk of suicide; the recently bereaved; and certain ethnic groups also go on this “at-risk” list. The person who is homeless and drifting is also likely to have a drinking problem.
One should always be on the look out for a hidden drinking problem with the client or patient who is frequently changing house, jobs, or relationships. Family presentations are common – marital disharmony or family violence, the spouse presenting with depression or the children with truanting, school failure, antisocial behaviour or neurotic symptoms. Criminal offences also suggest the need to ask about drinking.
Here, the essential background list derives from Chapters 6 and 7. In particular, one should be alert to the possibility of a drinking problem when the patient or client complains rather nonspecifically of “bad nerves,” insomnia, or depression. Phobic symptoms, paranoid symptoms, and dementia or delirium may all be alcohol-related. A drug problem may also be associated with a drinking problem. A suicidal gesture or act of deliberate self-harm always demands enquiry into drinking.
An account of the medical complications of heavy drinking is given in Chapter 5. In practical terms, one should be particularly alert if a patient repeatedly asks for a ‘certificate’, is a frequent visitor to the doctor’s office on a Monday morning, is suffering from malnutrition, is complaining of any gastrointestinal disorder or liver problem, has otherwise unexplained heart trouble, or is presenting with “epilepsy” of late onset. Bruising also may be a clue, as may burns that resulted from a cigarette being dropped on the skin while the drinker was intoxicated. Accidents of any sort may be alcohol-related, and 20 percent of those involved in road traffic accidents may be classified as problem drinkers (Mayou & Bryant, 1995).
The patient may declare the diagnosis by the smell of alcohol on their breath, by the bottle sticking out of their pocket, by their flushed face and bloodshot eyes, or by their tremor, but even the fact that they are obviously intoxicated can be overlooked if the possibility of drinking is not held in mind. The patient who makes jokes about their drinking should have those jokes taken seriously. Similarly obvious presentations may be seen on a visit to the home: bottles and glasses lying around, decoration neglected, and furniture reduced to a few sticks; the home may be a sad parody of a stage-set portraying decay. It would, however, be a mistake to think only in terms of such flagrant presentations and therefore overlook subtler clues.
Sophisticated, evidence-based screeners for drinking problems are available as Internet web pages and smartphone apps (see, e.g., www.checkyourdrinking.net), and patients are increasingly comfortable screening themselves and even receiving an ensuing brief intervention online where indicated (Cucciare et al., 2013; Cunningham et al., 2009). A fixed terminal in the waiting room of a clinic can easily mount such software and help open the conversation about the role of problem drinking in a service recipient’s life.
A number of laboratory tests are useful in the screening of populations for possible drinking problems – within, for instance, a routine medical examination when staff are recruited or undergo annual health checks. Laboratory tests are not by themselves diagnostic but are useful to help confirm a diagnosis in the individual case where excessive drinking is suspected but has not been admitted. A battery of tests will generally perform better than any single test. Indeed, a properly chosen array of currently available tests should detect more than 90 percent of people with an at least moderately severe drinking problem (Hashimoto et al., 2013; Niemela, 2007). A negative result does not rule out the possibility that excessive drinking has begun to adversely affect the individual’s life, and false positives also occur. Laboratory tests need to be interpreted shrewdly and in the context of all those considerations listed earlier.
Two characteristics of individual tests define their usefulness in detecting and diagnosing cases. The specificity of a test refers to the extent to which a positive result is indicative of the condition of interest. In this case, the condition of interest may be heavy drinking, drinking problems, or alcohol dependence, depending on the circumstances and reasons for screening. A nonspecific test for heavy drinking, for example, would show a positive result not just in heavy drinking but in a range of other unrelated disorders as well. The ideal test would be 100 percent specific, indicating that it only became positive as a result of heavy drinking. The sensitivity of a test indicates the extent to which it reliably detects every case of the condition of interest. For our present purpose, we would like a 100 percent sensitive test, which would always be positive in every case of heavy drinking, drinking problems, or alcohol dependence (as appropriate).
To date, no one has devised a 100 percent specific and 100 percent sensitive test for heavy drinking, drinking problems, or alcohol dependence. Different tests are more or less specific and sensitive, and these parameters vary with the group under study (e.g., dependent or hazardous drinkers). The extent to which these tests will serve practical diagnostic needs depends on the prevalence of heavy drinking, drinking problems, or alcohol dependence in the population in which they are being used. To understand this better, let us consider a fictitious illustration:
A new test for heavy drinking, “alcoholin,” has 95 percent specificity and 60 percent sensitivity. It is used to screen 1,000 apparently healthy employees at their annual medical review. Let us assume that 10 percent of these employees are actually drinking sufficient amounts of alcohol to be a cause for concern. How useful will the new test be?
Out of 1,000 employees, 10 percent (n = 100) are drinking too much, and 60 percent of these (n = 60) will be correctly identified by the test as being “heavy drinkers.” However, out of the whole group of 1,000, 5 percent (n = 50) will be identified as positive due to nonspecific (i.e., not alcohol-related) results of the test. Therefore, a total of 110 people will be identified by the test, and only 60 of these (55 percent) will actually be drinking too much. The “alcoholin” test is therefore of limited usefulness and must be followed by other tests and by more detailed inquiries in order to confirm whether or not each of the individuals testing positive actually is drinking too much. Furthermore, 40 people who are drinking excessively will not be identified by the test.
The problems illustrated by this example become more severe as the ratio of those with versus without the disorder departs further from 1 (i.e., as the base rate of disorder departs in either direction from 50 percent). Thus, if the prevalence of heavy drinking were only 1 percent, only 1 in 9 of those who tested positive with the same test would actually be heavy drinkers. Conversely, if used in a population where almost everyone had a drinking problem, then more than 9 out of 10 would test positive, including most of the few non-problem drinkers in the sample.
Let us now consider the actual tests used to screen for heavy drinking in populations, as well as to monitor clinical progress in ongoing cases. The most useful tests are described in the following sections.
Mean corpuscular volume (MCV) is a measure of the size of red blood cells, which may increase in response to heavy drinking due to a poorly understood mechanism affecting the developing cells. Sensitivity is 20–30 percent in hazardous drinkers and 40–50 percent in dependence, with a specificity of 64–100 percent (Conigrave, Saunders, & Whitfield, 1995). The sensitivity in women is higher.
If MCV has been elevated as a result of heavy drinking, it may remain raised for several months after a reduction or cessation of alcohol consumption. This is because of the relatively long life of red blood cells (about 120 days); the average cell size reduces as those of normal size replace the large red blood cells. Other causes of a raised MCV that affect the specificity include vitamin B12 deficiency, folic acid deficiency, liver disease, blood disorders, hypothyroidism, and smoking (Niemela, 2007).
Serum gamma-glutamyl transferase (GGT) is an enzyme that the body produces in response to alcohol ingestion. Serum aspartate aminotransferase (AST) and serum alanine aminotransferase (ALT) are also indicators of alcoholic hepatotoxicity, which may be elevated as a result of heavy drinking. Of these, GGT is generally considered the most useful as a screening test for heavy drinking. However, the sensitivity of 20–50 percent in hazardous consumption and 60–90 percent in dependence, along with a specificity of 55–100 percent (Conigrave et al., 1995), has led to its value being questioned. In many laboratories, GGT measurement requires a specific request because it is not included in routine liver function tests. If GGT has been elevated due to drinking, as in a relapse, it will fall again after abstinence is established. This occurs more rapidly than the restoration of MCV, with the level falling to approximately half after approximately 2–4 weeks of abstinence (Hashimoto et al., 2013). It may still take several weeks to return to normal depending on the level to which it had been raised.
Non–alcohol-related causes of a raised GGT include liver disease (alcohol-induced or otherwise), with the greatest increases being associated with biliary obstruction (blockage of bile flow from any cause), obesity, diabetes, pancreatitis, hyperlipidaemia, cardiac failure, severe trauma, nephrotic syndrome, renal rejection, and other drugs (e.g., barbiturates, anticonvulsants, statins, and anticoagulants; Niemela, 2007). With more serious liver damage, other biochemical parameters, such as the albumin level, clotting factors, and bilirubin, will also be altered; in such cases, there may be enduring abnormalities of some levels, even after prolonged abstinence.