Moderate alcohol drinking is recognised as a major health issue. Although end-stage cirrhosis and liver failure are the most visible and tragic results of alcohol dependence/addiction, there are many more people out there who drink regularly to excess but who have no physical or mental problems with it… until an abnormal blood test or a scan brings them in front of a doctor and the cold calculation is done. Recent studies (see below) show that many diseases, not just liver damage, are linked to alcohol use, and the maximum advisable weekly limits seem to go down every few years. So the conversation with a non-alcoholic patient who nevertheless drinks too much is a common one. Finding the right approach, and the right motivation, is hard. This week there is controversy about a new ‘2 days off a week’ message, with a prominent alcohol campaigner threatening to resign from Public Health England because the alcohol industry is involved in the initiative. And today, a Guardian columnist writes about procrastination. It’s hard.
In this dialogue a 55 year old patient has had a scan that suggests significant liver damage. But he feels perfectly well. The doctor (who may not be perfect here) tries to engage…
Dr: There’s evidence of liver damage here, Mr Jones. The most likely cause is the alcohol you drink. The fibroscan result was 9.
Patient: You think I’m an alcoholic?
Dr: No, you’re clearly not addicted as such, or ‘dependent’, but you drink enough to have caused damage to your liver. The scan is pretty accurate. [↓]
Fibroscan: a painless and non-invasive way of measuring the ‘stiffness’ of the liver, which equates to the amount of scar tissue (fibrosis). Severe scarring causing cirrhosis, and this can lead to liver failure, cancer, transplantation or death. The fibroscan provides a number, or score. Over 9 suggests you have developed serious liver scarring.
Patient: How do I stop it?
Dr: (Is this a serious question?) You need to stop drinking.
Patient: Doctor, do you drink?
Dr: Yes I do.
Patient: What would you think if someone told you you to stop drinking?
Dr: That’s a good question. I sit here every week, and tell people the same thing. That, although they are not “alcoholic”, by which I mean their day-to-day life is not affected by their addiction, they hold down their jobs, often they do very well in those jobs, they live with their families, that although they function perfectly well, nevertheless they are drinking harmfully [↓]
… and, I know that most of the time when I tell people that they need to stop drinking I may as well be talking to myself, or shouting out into the busy street below us here.
‘A person who is dependent on alcohol may feel a strong desire to drink and may have difficulty in controlling how much they drink. They may keep drinking despite knowing about or experiencing harmful effects. The body may become more tolerant to the effects of alcohol over time, which can lead to a person needing to drink more to feel an effect. If a person becomes dependent on alcohol, they can develop withdrawal symptoms if they stop or reduce their drinking suddenly.’
‘Drinking is considered harmful when it leads to physical or mental health problems such as alcohol-related injury, inflammation of the liver or pancreas, or depression. In the longer term the person may develop high blood pressure, cirrhosis of the liver, heart disease, some types of cancer or brain damage because of their drinking. Heavy drinking can also lead to relationship problems, problems at work, college or school, or violence.’
(Taken from National Institute for Health and Care Excellence website)
Patient:: And why is that doctor?
Dr: Because alcohol is a part of our lives.
Patient: Yes! Yes it is. So in telling me I need to stop drinking, you are telling me to remove a part of my life.
Dr: That’s a decision for you to make, isn’t it? Because the tests that you have had suggest your life may be shortened if you don’t.
Patient: Among the hundred other things that might shorten it, doctor. I am a little bit overweight, and I know that might be affecting my chances of a long life. Despite this spreading stomach, I like to cycle at the weekends, and went I went on holiday recently and admitted that I would be doing this in Austria, the insurance company wouldn’t tale me on. Said I was in a dangerous sport category. I often drive too fast. I used to smoke. Why should my life be shortened by alcohol, when there are so many other possibilities.?
Dr: I can only advise you on the reason for coming here, to this clinic. I can’t lecture you about other lifestyle choices. But I can tell you, the fibroscan suggests significant liver damage. And it’s not just through your liver that your life might be shortened. We know that there is a good correlation between cardiovascular disease [↓], strokes and cancer with alcohol use. So in a way the fibroscan is like an hourglass, telling us how your body is fairing, not just your liver, your whole body. It may be that your liver works perfectly well until the end of your natural life, but I can tell you that there are signs that your body is being injured.
The Lancet medical journal published a paper that caused a great deal of comment. Based on large numbers (599,000 drinkers), it suggested a real association between increasing alcohol use and ‘all cause mortality’. The graphs below show how the likelihood of death and cardiovascular disease rises with increasing alcohol use. The ‘safe’ limit appears to be 100g/week, which equates to 5 or 6 glasses of wine of pints of beer per week. Interestingly, the ‘tick’-shaped graph on the right suggests that cardiovascular disease may be less common in the 100g/week drinkers as compared to minimal drinkers (‘cardioprotective effect’).
Patient: That’s the problem doctor, the uncertainty. I could stop drinking now, but it might make no difference to my life. Except… to make my life less happy.
Dr: You need alcohol to relax then?
Patient: Just as you do doctor, probably. Just as so many of us doing our society. Perhaps I would rather benefit from those thousands of nights, meals, meetings with friends that are made more pleasurable and enlivened by alcohol, and accept this against a reduction in lifespan of 10 years [↓]. Perhaps instead of 85 I will live to 75, or instead of 75, just to 65. Perhaps, to me, that an acceptable price.
The Lancet article also includes a graph showing how much life you can expect to ‘lose’ according to how old you are now and how much you drink. A 45 year old man who drinks >350g/week alcohol will lose, on average, nearly 5 years of life compared to someone drinking <100g/week.
Dr: That’s a choice for you, Mr Jones.
Patient: That’s what I dislike. Sorry. You hand the burden of choice over to the patient and almost literally wash your hands of it. But you don’t frame it as a choice. You tell me I need to stop drinking, or else I die early. The way you put it, if I don’t make that ‘choice’, I am happily saying goodbye to years of life. That makes me look stupid. You don’t accept it as a balance of medical risk and psychological or social benefit.
Dr: I didn’t mean to be so paternalistic. But at the end of the day, all I can do is give you the advice based on medical evidence. It would be same if you still smoked, and you were at risk of having a fatal heart attack. I cannot stop for you. Only you can do that. There is some help available, maybe some medication too, although that’s usually for the seriously dependent. The amount you drink, something like AA seems disproportionate. Ultimately it’s down to whether you open the bottle tonight. When you see that cool glass in the fridge, can you stop yourself, for a night, maybe two.
Patient: But if I choose to ignore that advice, I know what you will write. In a few months’ time, when I see you again, you will write a letter to my GP that ‘despite medical advice I chose to continue drinking’, and that will put me in a certain category. The non-compliant patient. The man who doesn’t really value his life. The stupid patient.
Dr: No, I wouldn’t. I am more subtle than that. I understand addiction, dependence.
Patient: You said I wasn’t dependent.
Dr: Look, some of my patients are dying from liver disease as we speak. This week I have seen a young man bleed to death on the ward, his skin deep yellow, his muscles wasted, his breath foetid, his brain no longer able to recognise his own family. His own teenage daughter. That is the death that liver disease can cause. And if you are drinking actively, the window of opportunity for salvage, when you might have a liver transplant for instance, is closed to you.
Patient: You really think that could happen to me?
Dr: It is unlikely, but it’s possible. I can’t tell how rapidly your liver disease will progress. There are factors [↓] that we still don’t understand well that make some people more prone to liver damage than others.
Patient: Like what? Can’t you check them out?
Doctors run a series of tests to exclude other causes of liver damage (e.g. hepatitis C or haemochromatosis (a genetically inherited iron overload condition). But studies show that other genetic factors are involved in predisposition to the development of liver damage; these may be tested in the future. Although not strictly ‘inherited’, a person’s socioeconomic status is also strongly associated with the risk of alcohol related disease or death. (Graph taken from Fair Society Healthy Lives – The Marmot Review)
Dr: Some of them, not all. So I can’t reassure you, but I can’t threaten you with certain knowledge that your liver will fail either. But I can say that the only way to reduce the risk of you dying from liver failure, or any of the other alcohol related diseases, is to stop drinking.
Patient: And change my whole life. A change in life in exchange for a longer life. What value the pleasure it gives me? The friendships it cements, through conviviality, the sense of occasion? I play in jazz band at the weekends… I cannot imagine doing that without a few drinks…
Dr: You are talking about habit. If you want, you can change that. The challenge here is, I think, visualization. You do not see or feel the damage that is being done Mr Jones. It is genuinely silent. Unlike the smoker who sees her leg go black, or suffers chest pain, you will not feel anything from your liver until it reaches the point of no return. I don’t say this to scare you into abstinence…
Patient: Why not? Why not hit me with the worst picture. That, after all, is why I need to stop.
Dr: Most people would say haranguing patients is not productive.
Patient: Do it. Give us all the information. Then you know you have ‘educated’ us honestly.
Dr: I don’t get the impression it will have the desired effect. But there are ways to do it. They are called Brief Interventions. Perhaps this is one. Holding up a mirror, getting the patient to understand how much they are drinking, the risks. It works, sometimes [↓]…
Alcohol Brief Interventions (ABI) are delivered in primary or secondary care. A large meta-analysis showed that they successfully reduced alcohol use at 1 year by 38g/week, more in men than women strangely. Below are some pages from ABI booklets for staff in Scotland.
Dr: So, do you think you will stop?
Patient: I can say yes, it will make it easier to face you and leave, but to honest… not really. The benefit is too intangible, the threat invisible. It’s all so gradual, so marginal. I feel sorry for you. I really don’t know what you could say that would make me change. Are you going to see me again?
Dr: Not here. But perhaps, if things get worse…
Patient: If I go yellow you mean?