The Elephant in the Exam Room
Bill Loving, MD

Look, as doctors we all see alcoholics, but we usually don't address that problem in our patients. Hardly any of us had courses or training in medical school or residency to help us know anything about alcoholism. Besides, it's a lot more dramatic and awe-inspiring to deliver babies, do surgery, treat infections, or diagnose other illnesses. Alcoholism is a self-induced illness to some degree, and the patients with it are resistant, have denial, and, in the early stages, don't want our help. In fact, they may get insulted and never come back to see us if confronted with "you might have a drinking problem."
TIP: About 15% of the population can't control their drinking.

So, what's a doctor to do? Well, you can go ahead and ignore the primary problem and sew up the cut caused when the drunk fell and hit his head; treat the trauma from the drunk driver's car wreck; give more medication for the unremitting GERD or hypertension; add another psychotropic medication to the continued anxiety and depression; and/or you can address the underlying problem.
TIP: Alcoholism causes hypertension, GERD, many GI problems, and anxiety and depression.

If you look at alcoholism as a chronic disease, often genetically determined, then you won't be so judgmental or disdaining of the alcoholic's plight. To address the problem is to talk about it, and that can only be done in a matter-of-fact way without moral judgments, so it can be accepted by the patient. A little alcohol actually might be good for health, but too much is definitely injurious to every organ system (not just the liver), and is a progressive problem. Alcoholics can't drink just a little as "one is too much and 1000 is not enough." Alcoholics can't safely drink any. How much is too much to drink for the non-alcoholic? The Brits say no more than 21 drinks per week for males, and no more than 14 per week for females, with two days per week being alcohol-free. (This may be a bit high, however.) You must define "a drink", however, because I once had a patient who drank three drinks per day but I found out "a drink" for her was an 8oz glass filled with vodka and one ice cube. One glass of wine, one bottle of beer, and one shot of liquor contain about the same amount of ethanol, and each would equal "a drink."
TIP: Females don't metabolize ethanol in the gut, so more gets into their bloodstream.

In the public ER around 85% of problems coming through the doors are alcohol or drug related, while in a more middle-class or suburban ER the percentage is about 50-60%. Gastroenterologists see a lot of alcoholics as alcohol is very caustic to the whole GI track, and alcohol increases the risk of cancer of the esophagus, stomach, and intestine. Internists see plenty of alcoholics with hypertension, liver problems, and pancreatitis. Orthopedists fix the fractures of alcoholics and chemically dependent people caused by their risky and out of control behavior. Psychiatrists have a high percentage of chemically dependent people in their practices trying to self-medicate or suffering from anxiety and depression caused or aggravated by alcohol and drugs. Family practice doctors may wonder why it's so difficult to control a patient's diabetes or hypertension when alcohol may be complicating the whole picture. We all see alcoholics, and our therapeutic results will be much better when treating diabetes, hypertensives, anxious and depressed patients, and others if we can address the primary problem or the complicating problem which is often alcohol. Laboratory work can help sniff out an alcohol problem. On a CBC elevated MCV and MCH plus low platelets can point to a drinking problem. Elevated AST and ALT can of course point to liver problems and, remember, the GGT is more sensitive and goes up before these more standard liver function tests. An elevated GGT plus elevated MCV and MCH is almost always due to too much alcohol. If such lab abnormalities come up, and even if they are only slightly abnormal, it is best for the patient if the doctor talks to him or her with concern. And because alcohol problems are progressive, these abnormalities should concern the doctor. This is an opportunity for the doctor to address what may be the primary problem or at least a complicating one.
TIP: Elevated GGT +Elevated MCV +Elevated MCH = Alcohol problem

If you suspect an alcohol problem because of certain physical or lab findings, or because usual medications or remedies aren't working, the first thing to do is inquire about drinking. Most people can't tell you how much they drink, so it is helpful to ask the patient to keep track of their drinks per day on a calendar. It might help to ask a spouse or partner to help with this. See the patient back in two or three weeks and then try to ascertain if drinking is a problem If so, then set a goal with the patient to cut down to a more healthy level. Keep track again, and try to achieve the goal. If the patient is successful with this, then your therapeutic efforts and results will be much better, medications can work, and you will do a better job for your patients.
TIP: AA meetings can be found by calling 1411 or on the internet.

If the patient can't cut back then they may be alcoholic or at least be a problem drinker. You may have to revise your therapeutic plans, but do not be afraid to refer the patient to AA, to a specialist in addiction medicine, or a chemical dependency counselor. Better therapeutic results will definitely come if we don't ignore the elephant in the exam room.