Don’t pass me the drink

Nada Khan is an Exeter-based NIHR Academic Clinical Fellow in general practice and GPST4/registrar, and an Associate Editor at the BJGP. She is on Twitter: @nadafkhan

“He drinks a whisky drink, he drinks a vodka drink…and then, he doesn’t drink again ‘til next week.” (Song Lyric, Tubthumping, by Chumbawamba)

Dry January seemed like an apt time for the Canadians to bust up the party. The Canadian Centre on Substance Use and Addiction (CCSA), in new guidelines endorsed by Health Canada, recommend that Canadians should have no more than two alcohol-containing drinks per week. The Centre describes the negative consequences of drinking even up to 3-6 standard drinks each week, citing increased risks of colorectal and breast cancer and cardiovascular disease, alongside addiction, injury and violence.¹ The guidance was based on a principle of autonomy and clear communication around harm reduction, with the authors stating that ‘people living in Canada have a right to know’ about the risks of increased alcohol intake. The report also calls for mandatory labelling of all alcoholic beverages with health warnings, a recommendation which has really annoyed the alcohol lobby in Canada. Current UK guidelines are not to drink more than 14 units of alcohol a week, spread across 3 days or more, but acknowledge that there is no safe lower limit, and that no level of alcohol consumption improves health. Alcohol use is a major cause of morbidity and mortality; in the UK there were 9,641 deaths related to alcohol-specific direct causes (not including deaths attributed to alcohol), with an increase in the rate of deaths since 2020. Action to prevent harmful drinking may lessen this burden of disease, but what’s the role for general practice here in terms of alcohol harm reduction, and what’s the public health impact of this strategy?

The role of general practice and alcohol misuse has generally been set within a framework of identifying and managing the problem, including primary and secondary prevention of alcohol morbidity. In terms of screening, up to 40% of GPs surveyed say that they routinely ask about alcohol use, but those working in primary care cite several barriers in screening including a lack of financial incentives, lack of training, being busy, and the impact on the doctor-patient relationship.² A qualitative study of GPs in the North of England found that primary care practitioners felt that even as a high risk group, older people’s cultural views about normal drinking made it difficult to motivate people to change, describing alcohol use as a sensitive topic that could ‘fracture’ the doctor-patient relationship. The practitioners did emphasise the right for older people to make informed decisions to use alcohol and take risks, mirroring the motivations of the CCSA in providing clear information to guide decision-making in Canadian drinkers.³

A substantial body of research looks at the efficacy of brief interventions to reduce alcohol misuse in practice. A Cochrane review of brief alcohol interventions in primary care found ‘moderate-quality’ evidence that brief interventions reduce alcohol use in hazardous drinkers compared to doing nothing, and that brief interventions were as good as longer counselling programmes. What is a brief intervention? The Cochrane team defined this as a single session, and up to a maximum of five sessions of verbally-delivered information or counselling.⁴ So not the kind of thing we might do in a single consultation, but probably the kind of service we might refer to. For some groups, and in some settings, these interventions might have their place, but It’s unclear how minority groups, women, older drinkers, or different socioeconomic groups might perceive these interventions, so applying these in practice might not be so simple. Writing in the BMJ, Jim Cambridge and Richard Saitz suggest that we need to rethink brief interventions for alcohol in general practice altogether, citing a weak evidence base, questions about actual efficacy, and suggest that approaches to manage alcohol misuse need a more joined up and public health approach considering the patient rather than the use, and other physical and mental health issues. Their analysis article is well worth a read, if not only for a list of future research questions that they feel need answering to actually underpin any real shift in changing alcohol consumption behaviours.⁵

What do the general public think about the role of GPs and policy in reducing alcohol-related harm? A group of researchers spoke to patients at six practices in North London and found that UK drinking guidance was seen as too general and irrelevant to their individual experience. Participants set their own limits based on intuition and individual tolerance, and framed problematic drinking as drinking that was harmful or demonstrated a dependence on alcohol. Mirroring previous research, participants didn’t mind when their GP asked about drinking, and felt that their doctor was their preferred source of help for alcohol use. The authors suggest that future guidance to the public should challenge the conception that alcohol misuse is synonymous with dependency, and should demonstrate tangible harms relevant to people at different life stages and with different lifestyles. Interestingly, participants felt that other public health messages, like anti-smoking campaigns (don’t smoke) and anti-drug campaigns (don’t do drugs), were much more unambiguous in their message, underlining the mixed messages of safe drinking guidance.⁶ Again, this is interesting given the approach from Health Canada to provide a clear message about the harms of drinking.

So, people don’t mind if their GP talks to them about alcohol use, and the individual approach that healthcare professionals provide, even as brief interventions, have been shown to work (sometimes) in (some) populations. But some GPs don’t have time, or the right training to ask, and feel that talking about alcohol might fracture their relationship with patients. And overall, some people feel that the messaging is unclear within a societal context of fairly liberal alcohol use here in the UK. If a clearer health message is needed, Health Canada has certainly delivered. Whether the new guidelines actually change drinking habits remains to be seen, but might shift perceptions about norms around alcohol use. Will we see warning messages on bottles of wine similar to what we see on cigarette packets, alongside other public health measures like minimum price for alcohol and increased regulations on alcohol advertising and marketing? Canada seems poised to act as a natural experiment to guide future thinking about alcohol public health policies in other countries.

References

1. Paradis CB, P.; Shield, K.; Poole, N.; Wells, S.; Naimi, T.; Sherk, A. Canada’s Guidance on Alcohol and Health: Final Report. Ottawa: Canadian Institute on Substance Use and Addiction (CCSA); 2023.
2. Wilson GB, Lock CA, Heather N, Cassidy P, Christie MM, Kaner EF. Intervention against excessive alcohol consumption in primary health care: a survey of GPs’ attitudes and practices in England 10 years on. Alcohol Alcohol. 2011;46(5):570-7.
3. Bareham BK, Stewart J, Kaner E, Hanratty B. Factors affecting primary care practitioners’ alcohol-related discussions with older adults: a qualitative study. Br J Gen Pract. 2021;71(711):e762-e71.
4. Kaner EF, Beyer FR, Muirhead C, Campbell F, Pienaar ED, Bertholet N, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2018;2(2):CD004148.
5. McCambridge J, Saitz R. Rethinking brief interventions for alcohol in general practice. BMJ. 2017;356:j116.
6. Khadjesari Z, Stevenson F, Toner P, Linke S, Milward J, Murray E. ‘I’m not a real boozer’: a qualitative study of primary care patients’ views on drinking and its consequences. J Public Health (Oxf). 2019;41(2):e185-e91.

Featured photo by Dylan de Jonge on Unsplash