Modules

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: Mrs. Alton.

    Patient: Hello Dr. Crane.

    Dr. Crane: Hi. So, what brings you in today Mrs. Alton, it’s too early for your follow up appointment?

    Patient: Well, I think I have problems with my blood pressure medication and my son thinks that I should go into a home because he thinks I’m alone too much and that is just crazy.

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

    Patient: No, but I think maybe he’s feeling a little guilty because 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 can really because I’ve got all day to do it and he can only drop by a couple of times a week.

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

    Patient: No I haven’t but I have been losing my balance and sometimes falling. I’ve told my son that I’m sure it’s my blood pressure but he just doesn’t listen.

    Dr. Crane: Mrs. Alton the nurse checked your blood pressure when you came in today and it’s under control. But you say you’ve been falling.

    Patient: Well, look I’m covered in bruises and sometimes I feel woozy.

    Dr. Crane: What do you mean, woozy?

    Patient: Well I have trouble keeping my balance and I’ve been falling down.

    Dr. Crane: Are you feeling that way right now?

    Patient: Oh heavens no, I wouldn’t leave the house if I were feeling like that. This just seems to happen at night.

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

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

    Dr. Crane: Mrs. Alton we’ve had that conversation before and you agreed that you’d give up alcohol so I could put you on this new medication.

    Patient: Well I did. I’m just having sips of sherry, you know.

    Dr. Crane: Listen, sipping sherry is still drinking. Alcohol is alcohol. Now, how many glasses do you have in an evening?

    Patient: Not a lot. I just sip while I’m watching TV because, you know, it’s so boring and being alone because my husband is gone now. There’s just never anything interesting to watch on TV these nights.

    Dr. Crane: You know Mrs. Alton at your age and having high blood pressure and living alone, I really don’t think you should be drinking and maybe that’s what your son is 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: Well, the baby is growing.

    Patient: That’s good.

    Physician: And you seem to be fine, did you have any concerns or questions?

    Patient: Well, I am more tired now running around after my husband’s two kids and the pregnancy and I was wondering, I read an article, how much alcohol is safe to drink during pregnancy?

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

    Patient: 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?

  • The pregnant drinker, version 2

  • Physician: Well, the baby’s growing.

    Patient: That’s good.

    Physician: And you seem to be doing fine as well. Did you have any concerns or questions at this point?

    Patient: Well I am a lot more tired now, running around after my husband’s two kids and the pregnancy and I was wondering I read an article, how much alcohol is safe to drink during pregnancy?

    Physician: Well actually what we recommend is no alcohol, but why? Have you been drinking?

    Patient: Well, not much.

    Physician: And what do you mean by not much?

    Patient: I started off with about half a glass in the evening. Now I’m up to one sometimes two.

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

    Patient: About two months ago. Tom works nights now and it gets kind of lonely.

    Physician: I see you’re lonely.

    Patient: Yeah and my neighbor she comes over when the kids go to sleep and, you know, I look forward to her company. The wine helps me relax.

    Physician: And do you do this every night?

    Patient: Almost every night but back to this article that I was reading, it’s about fetal alcohol syndrome and I’m kind of worried. I don’t know what to do. It’s not like I drink to get drunk or anything.

    Physician: Well I’m very glad you told me. Drinking during your pregnancy is not recommended but can you tell me, do you ever have more than two?

    Patient: No, I always stop at two. Like I said I don’t drink to get drunk.

    Physician: All right and when you see a full glass are we talking a small or big glass?

    Patient: Just a regular glass.

    Physician: Okay. Is there any way you could drink something non-alcoholic when the neighbor comes to visit?

    Patient: Sure but it wouldn’t be that much fun and I really look forward to her visits. Anyway, will this affect the baby?

    Physician: Well, so far the baby is growing and there is no sign that it’s underweight and that’s positive but we won’t know until the baby comes if there are any other effects. See fetal alcohol syndrome or fetal alcohol effects don’t always show up right away.

    Patient: But it is more likely to happen in heavier drinkers, right?

    Physician: Unfortunately, it’s been recently found that there are no safe amounts of alcohol or safe times to drink during a pregnancy. Yes, fetal alcohol syndrome does occur in babies, more often to babies born to heavier drinkers but that’s not always the case. See, the alcohol crosses the placenta and what may seem like a small amount of alcohol in a grown woman is actually a pretty high concentration for the little one.

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

    Physician: We don’t know that yet. There’s no point in beating yourself up it won’t do any good, any stress that you feel is also not good for the baby. Tell you what, I’ll provide you with various information on the matter such as the effects of alcohol during a pregnancy and different ways of coping with the stress and loneliness. Does that sound good to you?

    Patient: Sounds good.

    Physician: Great.

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:


 

Next: Behaviour disorder: Attention deficit hyperactivity disorder (ADHD)

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