About 20% of general medical and surgical inpatients will have significant alcohol problems, but in only 4% will these be the reason for the admission. Eight per cent of patients will be at risk of alcohol withdrawal. These patients can be identified by taking note of the reason for admission, a careful drug and alcohol history, and where appropriate, doing a blood alcohol concentration. The patients most at risk are males under the age of 40, admitted with trauma. In older patients, i.e. older than 65 years, benzodiazepines are more likely to be the substances causing concern, about 35% of older patients are taking them. Patients who are using illicit drugs will present either in withdrawal, or with one of the complications of drug use, and people with a dependence on opiates prescribed or otherwise, will often have a chronic pain syndrome.
In family practice, alcohol related problems are likely to be of a more nonspecific kind such as poorly controlled hypertension, alcohol complicating other management of diabetes, episodes of trauma, etc. Also family problems and domestic violence may be encountered. This is also the setting in which patients will present with anxiety states, situational problems and chronic pain syndromes seeking prescribed sedatives or narcotics. Illicit drug users will also present with a variety of drug seeking behaviours.
The following is based on the Physicians Handbook of the Addiction Research Foundation, Toronto, Canada,1986, Devenyi P, Saunders SJ (eds). This does require a little practice in tactfully overcoming evasion and denial and incorporating relevant questions in the general history in a natural way.
Avoid labels such as “alcoholic” “addict” etc. even if the patient applies them to themselves.
Include questions about alcohol/drug use as a standard part of a medical history usually along with questions about diet, smoking and other lifestyle issues.
Only accept an answer which you can record in a standard quantitative way (see below) “occasional” or “social drinking” are inadequate. When quantifying alcohol consumption, make a guess, add 50%, then get the patient to correct you.
Use direct questions e.g. “How many Valium pills do you take?” “What strength are they?” or, “Have you had a drink driving charge” rather than oblique inquiries seeking the same information.
Learn to be both persistent and friendly. Patients do expect to be questioned about their lives by their doctors and will not be offended if it is made clear that vague or evasive answers will not be accepted provided this is done courteously.
Do not discuss rationalisations. This will divert the interview. If the rationalisation is short, wait until it is finished and then return to the issue. If long and involved, interrupt the patient and lead them back to the issue. Again, be firm but friendly.
Where possible use collateral information from spouse, other family, friends etc. This must be done with the patient's permission preferably in their presence.
See alcoholic content of various drinks.