Mental health

Substance abuse disorders: Alcohol

The topic of alcohol consumption/abuse comes up in many conversations between physician and patient. Physicians are taught to screen all patients for their drinking habits. The CAGE questionnaire is commonly used, either in written or oral form:

  • Do you ever feel you should Cut down on your alcohol consumption?
  • Have you been Annoyed by criticism of your drinking?
  • Do you ever feel Guilty about your drinking?
  • Do you ever have an Eye-opener (drink in the early morning)?

Following are three scenarios about alcohol. One concerns an elderly woman; the other two are two versions of a conversation with a pregnant woman.

The elderly drinker

An elderly woman comes to see her family physician because she is falling a lot. She thinks she needs her blood pressure medication adjusted.

Analyze the interview then proceed to the “Reflective exercise.”

  • Dr. Crane: So, Mrs. Alton, what brings you in today? It’s not time for your regular follow-up appointment.

    Mrs. Alton: No, I … I think I have problems with my blood pressure medication. And … my son thinks I should go into a home, because uh, he thinks I’m alone too much at home, and … and, it’s crazy.

    Dr. Crane: Does he have a reason to think that you can’t manage on your own?

    Mrs. Alton: Well, I think maybe he’s feeling guilty because, you know, I do all the gardening and the work around the house, and he doesn’t have a chance to give me a hand. And actually I can do more than he could really, because I’ve got all day to do it. He’s got to go to work.

    Dr. Crane: Well, he must have a reason to think that you can’t manage on your own. Have you been forgetting things?

    Mrs. Alton: Uh, no. Um, I … I haven’t, but uh … I have been falling, but uh, um … I’ve told him I’m sure it’s my blood pressure but he won’t … he just doesn’t listen.

    Dr. Crane: Mrs. Alton, the nurse took your blood pressure when you came in today and it is just fine. Now, you say you’re falling?

    Mrs. Alton: Well, look. I … I’m covered in bruises, and I … I’m feeling whoosy.

    Dr. Crane: What do you mean whoosy?

    Mrs. Alton: Well I … I have trouble keeping up right. You know like I … I’ve been falling over.

    Dr. Crane: Well, do you feel that way right now?

    Mrs. Alton: Oh heavens no. I … I wouldn’t come out of the house if that happened, you know. But this only seems to happen at night.

    Dr. Crane: Uh, Mrs. Alton have you been drinking again at night?

    Mrs. Alton: No, I’ve just been having my sherry.

    Dr. Crane: Well, I hope you remember we had that conversation and you agreed with me that you were going to give up the alcohol once I put you on that medication.

    Mrs. Alton: Oh, I did. I’ve just been having sips of sherry, you know.

    Dr. Crane: Well, there is no such thing as just sips of sherry, you know. Alcohol is alcohol. Like, how many would you have a night?

    Mrs. Alton: Well, you know …

    (Dr. Crane sighs)

    Mrs. Alton: I just sip while I’m watching TV because, you know, it’s boring, you know. And being alone, because Bob isn’t there now, and … and … and, uh, there is nothing on TV these nights to watch.

    Dr. Crane: Well, you know, with your age and having high blood pressure and living alone, I don’t think you should be drinking. And maybe that’s what your son’s worried about.

Reflective exercise

Analyze this interview and consider the following questions:

  • How might the information gathering about alcohol consumption have differed if the physician had not known the patient as well?
  • Does the patient show insight into her problem? How does the physician determine this?
  • At what stage of change is she in? (By the Prochaska method. See “Indigenous health”).
  • What technique(s) does the physician use to initiate a behaviour change discussion?
  • Note that the physician does not use the CAGE questions. If he had, what score would you have expected?

The pregnant drinker

There are two versions of this scenario. Watch both before doing the “Reflective exercise.”

A young woman comes for a routine ante natal check-up.

  • The pregnant drinker, version 1

  • Physician: The baby is growing.

    Patient: Uh-hm.

    Physician: Let me give you a hand here.

    Patient: Well, thank you.

    Physician: Oops. Okay, and things seem to be fine. So, are there any other concerns?

    Patient: Ah, well, I’m a little tired, because now there’s two kids and the baby, as opposed to just one.

    Physician: Uh-m.

    Patient: And, also, I was reading in an article, and I’m wondering how much alcohol is safe to drink during pregnancy.

    Physician: Well, actually, what we recommend is no alcohol.

    Patient: Oh.

    Physician: Why, have you been drinking?

    Patient: Well, you know, not much.

    Physician: What do you mean by not much?

    Patient: Uh, just sort of started with a half of glass in the evening, and well, now it’s more like a full glass, sometimes two.

    Physician: Okay, and when did you start with a half of glass?

    Patient: Uh, few months ago. Tom got a new job, and now he works most nights and it gets kind of lonely.

    Physician: So, it’s the loneliness.

    Patient: Yeah. I mean, my neighbour comes over after the kids go to bed, and it’s nice to have the company, you know. She … I guess the wine helps me relax, just a bit of down time.

    Physician: And is that every evening?

    Patient: Well, most evenings, yeah.

    Physician: Okay.

    Patient: And anyway, the article that I was reading was about fetal alcohol syndrome and now I’ve been kind of worried, and, you know. I don’t really know what to do. It’s not like I’m drinking to get drunk or anything like that.

    Physician: Well, I’m glad you let me know. Your instinct to be worried is right.

    Patient: Okay.

    Physician: It is better not to drink during pregnancy. Um, do you ever have more than two?

    Patient: Well, no, I seem to be able to stop at two, but I mean, just like I said, I’m not trying to get drunk or anything.

    Physician: Okay, and when you say a full glass, is that a small glass, is it a big glass?

    Patient: Uh, just sort of a regular wine glass.

    Physician: Okay. Is there any way that you can visit with your neighbour and drink something non-alcoholic?

    Patient: (laughs) Well, that’s not as much fun.

    Physician: That’s true.

    Patient: And, I just, I find myself looking forward to the company and …

    Physician: Uh-hm.

    Patient: Anyways, will it affect the baby?

    Physician: Well, so far the baby seems to be growing and there is no sign that it’s small, and that’s positive.

    Patient: Okay.

    Physician: We won’t know until the baby comes if there is any other effect. Fetal alcohol syndrome or fetal alcohol effects don’t always show up right away.

    Patient: But is it more likely to happen to somebody who drinks heavily?

    Physician: Unfortunately it’s been recently found that there are no safe amounts, or safe times to drink during pregnancy. Yes, it does occur more often fetal alcohol syndrome in babies born to heavier drinkers …

    Patient: Okay.

    Physician: … but that’s not always the case. See, alcohol crosses the placenta and when uh, a baby is developing what might seem like a small amount to a grown woman, can actually be a pretty high concentration for the little one.

    Patient: So, I’ve been putting my baby in danger.

    Physician: Well, we don’t know that yet, and beating yourself up isn’t going to help at all. So … any stress that you feel is also not good for the baby. So why don’t we get you some information, okay? And that way you can understand better the effects of alcohol and we could talk about other ways of relieving stress, and so on. Okay?

    Patient: Okay.

  • The pregnant drinker, version 2


    Physician: Well, the baby is growing.

    Patient: Good.

    Physician: And you seem to be fine. Any other concerns?

    Patient: Oh, well, I feel a lot more tired after running after two kids and being pregnant this time around. And um also I was wondering, because I just read this article, how much alcohol is safe to have during pregnancy?

    Physician: Actually what we recommend is no alcohol. Why, have you been drinking?

    Patient: Well, you know, not much.

    Physician: What do you mean by “not much”? Drinking during a pregnancy is quite serious. Haven’t you ever heard of fetal alcohol syndrome?

Reflective exercise: The pregnant drinker

  • Note the difference in the two conversations between the pregnant patient and the physician. You can review the material on behaviour modification found in “Indigenous health.”
  • In version 1, what technique(s) does the physician use to initiate behaviour change?
  • Would you be able to determine from this conversation if the patient has a substance abuse problem?


In version 1, at what stage of change is the patient in?

  • How long did the intervention take?
  • How successful do you think it will be?
  • Would you be able to determine from this conversation if the patient has a substance abuse problem?


In version 2, at what stage of change is the patient in?

  • How long did the intervention take?
  • How successful do you think it will be?
  • What technique(s) does the physician use to initiate behaviour change?

There is evidence that for many patients, brief interventions are helpful in reducing alcohol consumption. Read the following articles for more information on alcohol abuse:


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