In this blog, addiction psychiatrist Dr. Rebecca Lawrence discusses the topic of substance abuse and addiction, which may be triggering for some readers.
The last eighteen months have been hard for many, not least for those who use alcohol or drugs to alleviate their pain.
I am an addiction psychiatrist in Scotland, where we have been lucky enough to retain addictions as a popular sub-specialty of general adult psychiatry, although training numbers are worryingly low in England. We try to provide the best care we can, but sadly the pandemic has not treated our patients well, and drug-related deaths and alcohol-specific deaths have risen to a new high during 2020. These figures may appal us, but they are likely to be the tip of the iceberg, and it is important to also remember the many other alcohol-attributable deaths and all the suffering that we cannot measure.
I work in an eight bedded specialist in-patient unit, where most of our patients are admitted for detoxification, often physically ravaged by the effects of alcohol, and levels of harm have risen, possibly due to a reduction in bed numbers. The Scottish Government has committed money to reduce drug deaths, and this is to be lauded; but the announcement of the alcohol-specific deaths received notably less press, and this is puzzling.
Alcohol causes a lot of problems for people and is no respecter of anyone. It is responsible for many admissions to general hospitals and is one of the commonest comorbidities in those with psychiatric disorders, but often it remains hidden until it has caused irreversible damage.
How to speak with patients about their alcohol consumption
I am sometimes asked to see or discuss patients in general psychiatry wards, and it is becoming obvious to me that we are not always comfortable asking too much about alcohol.
I use the word ‘We’ deliberately, as I remember that when I was a junior doctor, alcohol consumption was one of the sections of the patient history that I was most often guilty of forgetting. Indeed, this was one of the reasons that I decided to work in addictions, when I realised just how important it was.
But why is this? Is it just forgotten, or not seen as important in the context of acute mental illness? Is it hard to ask about, given an assumption that people may be offended or feel stigmatised? For some, it may be that their own drinking is something they do not like to think about, and it can be easier to avoid that of others. There is a fine line between social and heavy drinking for all of us, and the numbers and units can be very blurred.
We need to teach the skills of enquiry, so that alcohol consumption can be raised without embarrassment, and patients feel safe disclosing. An example might be when the junior doctor asks the patient (let us say the patient is also a doctor): ‘You don’t drink more than fourteen units weekly, do you?’ The patient, condemned and shamed, cannot disclose that they actually drink fourteen units in a morning alone. It has become impossible.
It is my belief that the gentle art of motivational interviewing is underused. Its principles, particularly that of non-confrontation, can be applied to all psychiatric history taking — and, indeed, to life in general.
Effects of the pandemic
Returning from the individual to the terrible issue of the deaths — what can we do? The picture had been improving in Scotland, likely due to Minimum Unit Pricing, which was finally introduced in May 2018.
Unfortunately, the pandemic then intervened, and the problem appears to be that many of those who were already drinking at risky levels may have increased their consumption, leading to harm. Others have reduced their drinking, such that overall consumption may be the same or less, but this has not prevented an overall increase in harm.
During the pandemic, when few patients were being seen by services, there was a necessary move to harm reduction by phone, and patients were encouraged to keep drinking, rather than run the risk of seizures or delirium tremens (altered mental state and nervous response characterised by tremor, anxiety, nausea, vomiting, and insomnia) with few if any detoxifications being provided. Some excellent guidance was put together for both staff and patients, but it was ultimately one more situation where staff were unable to do what they felt was right, given that they were having to encourage patients to keep drinking, even when potentially harmful.
Even though the risk of stopping drinking at home without support was potentially worse, staff suffered the psychological effects of making decisions that they would not have made in normal circumstances, described by Professor Greenberg and others as moral injury.
Current service provision for alcohol addiction
This opens up the knotty issue of services generally, and how we help people. I think this can usefully be summed up in terms of resources and connection; in other words, we need sufficient resources to be able to treat people, offering the full range of interventions, and we need to connect our services, so that however people present, they will get the right help. I’m not convinced this is always happening just now, despite the best efforts of many.
I would like to justify this by touching on the complexity of alcohol use disorders. As I said earlier, many of our patients have some other psychiatric disorder as well as their alcohol use, and many have a wide range of significant physical health problems.
Much of the psychosocial support required can be effectively delivered by third sector workers, but this can easily become the default in times of austerity. These workers cannot be expected to identify or treat such issues, or indeed to supply medication for relapse prevention. The latter should be available to all who need it and requires monitoring, which may not be possible in primary care, which is more stretched than ever. We should be aspiring to provide the best quality, evidence-based treatments for our patients, in a timely fashion.
What the ideal service would look like
I think, to sum up, I will outline my ideal service.
We have some bits of it, in some places, but not all. All patients, wherever they present, will be asked about alcohol, in an empathetic fashion (I know not all will engage). If they disclose a problem, they will be directed, quickly, to the right level of help, which will include high quality screening of physical and mental health and monitoring and treatment where necessary. This will include disclosure in primary and secondary care, prisons, educational institutions, workplace — anywhere. If they are alcohol dependent, and require and wish detoxification, this will occur within 3 weeks (community or in-patient), with intensive follow-up and support.
People will not be excluded from services because they don’t drink enough — they may do so in a few years’ time if they are. Rehabilitation (residential if required) will be available for anyone who needs it and will not be a last ditch offer. Some of this may be carried out by health professionals and some by third sector workers, but there will also be easy access to social work, occupational therapy, and psychology where required. There will be excellent community and in-patient services to support those with alcohol related brain damage — who will be far fewer in number due to the effectiveness of the services.
It all sounds rather expensive, but I think we might actually save some money. And we would definitely save some lives.