Ask An Expert: Sarah (GP)

These ‘Ask An Expert’ posts are interviews I’m carrying out with trained individuals who come into contact with people struggling with booze. The idea is to humanise and demystify the clinical/medical field for us all, to draw information from these kind and knowledgable people, and hopefully in some instances empower us to reach out more for the great help that is available in the community.

Today’s expert is Sarah, a GP (General Practitioner) who works in the upper North Island.

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Mrs D: How often do patients voice to you that they are worried about their drinking?

Sarah: They have often come to tell me, but they won’t tell me unless they trust me. So I try to be as non-judgemental, open and caring as I can so they can get it out. The stigma is still incredible, and you must just shut up and listen. Probably one patient a day, and I think it would be two if it wasn’t for time pressure and the fact that appointments are so artificially short (12-15 mins). People hint, and I have to beware the patient admitting it with their hand on the door i.e. they trust me at the last minute. If I am swamped already, I let them go and make a note to follow up next time. If I sense a road in, an opening up, I will make the next patient wait because being real – opening up – is quite rare and that’s the moment I have to strike to help them make the change.

Mrs D: Do you sometimes suspect that a patient’s drinking is affecting their health even though they are not admitting it? What signs would give that away?

Sarah: The blood work gives it away. A bottle (or more) a night changes your body chemistry. You’ll have an increased MCV (haemoglobin) and you’ll have a fatty liver and elevated liver enzymes. You confabulate, you are tired, you are dehydrated, fatigued and frankly, not well. It’s not suspect, it’s pretty obvious. There are usually relationship difficulties, as those who love you will have pointed out the problem before your GP did. Sometimes you’ll have a drink-drive charge or will have lost your job. There are usually mood problems, as often a mental health difficulty will be being ‘self-treated’ with alcohol.

Mrs D: What are the most common physical symptoms that a patient could experience from drinking too much?

Sarah: Lets start with the brain. You are killing and poisoning your synapses with alcohol, so you will notice that your thinker isn’t working as well as it used to. You might be forgetful, irritable, fatigued, depressed, tired, or have emotional outbursts. You might have blackouts, moments when you cannot remember emotional or sexual transactions, faints or periods of not being conscious. Look for interference with your normal functioning. Also – your liver will be facing a meltdown, your skin will be dehydrated, your heart will be misbehaving and of course your risk of cancer will be greatly increased.

Mrs D: What about emotional symptoms?

Sarah: If I had a chocolate fish for all the “tired all the time” patients I order a battery of tests on, I would have a large aquarium. All due to the unaccounted and damaging effects of alcohol.

Mrs D: If someone appeared to be exhausted and tearful would you wonder if alcohol was playing  a part in their state of mind? How would you approach that subject with a patient?

Sarah: I’d ask: “How much do you drink? How often? Are you worried about it? How does it make you feel? Does it affect your function? Are those who love you worried? Have you ever stopped? What do you want to do about it today?” I do this only if I think they can handle the truth. Here is a New Zealand symptom checker. We are also taught to use this questionnaire which is validated and reliable. Also this one.

Then I offer a menu of helpful solutions. Living Sober and AA. I recommend Alcohol & Drug clinics. I recommend books (here). I use counsellors. Sometimes medication might help, and an addictions specialist is a good person to involve if your problem is full blown. There are also good counsellors available on helplines.

I will get a forensic history, because an alcohol problem often involves police, lawyers, children’s custody and marriage breakdown. I will also include a family history as mental health and alcohol tolerance, dependence and abuse is passed down genetically. See here the presentations from one of the latest Royal College Addictions conference. Your behaviour can be predicted by your ancestors predilections, so ask about that Wild Uncle!

Mrs D: How honest do you think most people are when asked about how much they drink?

Sarah: I usually double it to get a real estimate, in my head, so I know what the real damage is. I need to know the extent so I don’t go hunting for some mysterious other cause.

Mrs D: A lot of us problem drinkers are nervous to admit the truth, even to ourselves. What do you think is the best way to get people to start being honest to their GP about their alcohol consumption?

Sarah: To be honest, most people already know it is a problem – it is the consequences of reaching that decision in their head that they fear. So breaking down the fear, into small bite sized chunks, is our job. I think if you can just get yourself in the door, and then quit throwing red herrings in our way (“I’m tired”, “My wife hates me”, “I must be vitamin deficient”) then the GP won’t go chasing all those mirages and you’ll have more time from your 15 minutes or $40 worth.

Mrs D: Why should people talk to their GP if they are secretly worried about their drinking? What can a GP do to help?

Sarah: GPs are trained to care about folk, and help them on their journey. That doesn’t mean that your GP is secretly Superman. It means that if you ask for help you should receive the signposts to get you to the right place for you. If you don’t – there will be a reason why. Real relationships in life require trust, honesty and respect. If you don’t feel your doctor is giving these to you, perhaps you need to change docs.

Mrs D: Broadly speaking what do you say or do if a patient admits their drinking might be a problem?

Sarah: I shut up. Because I want to hear them. I ascertain using brief motivational interviewing where they are on the cycle of change. And then I offer a menu of options and see if they want or need anything from the menu. I also make sure they are safe (suicide, domestic violence, driving). This is a lot to do between coughs, colds, contraceptives and heart attacks, so I don’t muck around. If someone is having a real crisis I use the crisis team at the local DHB, and I will very, very, very occasionally recommend a direct admit. About once a year. Most of the time it is reflective listening – as most people already know where they are at and where they are heading to – it’s just a nudge they need to the next level.

Mrs D: What other advice do you have for any person reading this who might be scared to talk to their GP?

Sarah: Go with a friend. Use a note and hand it over. Ask the practice nurse to break the ice by saying it is about alcohol so we know what’s coming and can be better prepared to help. Or take your loved one – a husband, wife, child or parent – who can help you spill the beans. Once the beans are named you can get on and make a recipe for your new life.

Mrs D: Anything else you’d like to add?

Sarah: Beware heavy drinking masking a mood disorder. Often addiction has blown up because of untreated underlying mental health issues. May I recommend right now doing a ‘Kessler’ test on yourself.  Click here to complete the questionnaire and treat it as a ‘polaroid’ of where your mood is at.  If you are moderate to severe your alcohol use is probably contributing. It is a useless drug, it takes a bad day and makes it worse.

If you want to work on improving your mental health try Headspace. It’s brilliant. Or use this kiwi resource called CALM. It is peer reviewed and the creator is a PhD in happiness (true!) and also Psychiatry. Also check out John Kirwin’s depression site or Australian site Black Dog.

If online resources aren’t for you then use the old fashioned ‘call a friend’. The oxytocin released from bonding and community is worth more than a top shelf snifter, any day. I believe this is why groups like NA, AA and Living Sober successfully function. We are a communal animal.

Learn how to open your mental toolbox and tinker with your mind. The drugs don’t work.