Many doctors are on board with new guidelines urging them to ask patients about alcohol use, but they also note hurdles – people lose track of how much they drink, some lie, and many don’t know what constitutes a single serving.
Dr. Ginette Poulin, a general practitioner specializing in addiction medicine in Manitoba and Ontario, said it’s important for doctors to normalize these conversations because early detection of high-risk drinking is key to preventing serious health problems, the same as routine screening for diabetes or high blood pressure.
“If people disclose to you, ‘I drink about two drinks in the evening,’ you could probably safely double what is said as a practitioner to gauge where their drinking is really at because we know people feel shameful,” she said.
Patients often minimize the amount they drink, perhaps because they don’t realize that a nine-ounce glass of wine amounts to nearly two standard drinks, said Poulin, one of nearly three dozen authors of a clinical guideline document published last week in the Canadian Medical Association Journal.
The guideline for family doctors encourages them to ask patients how often and how much they drink to determine potential excessive drinking patterns. That includes asking female patients how often, in the last year, they have had more than four drinks on one occasion, and asking male patients how often they have had more than five drinks.
The guideline recommends doctors could also delve deeper by asking four questions from the so-called CAGE questionnaire – whether the patient has ever considered cutting down, is annoyed by criticism of their drinking, feels guilty, or takes an early-morning drink to start the day.
The Canadian Centre on Substance Use and Addiction released separate guidance earlier this year saying more than two drinks per week are related to escalating health risks. An estimated 57 per cent of Canadians aged 15 and older exceed that recommendation, the guideline notes.
Hospital admissions related to alcohol use, including from injuries and seizures, suggest people should be asked about consumption, Poulin said. A form that patients complete when registering with a new doctor could include questions about alcohol use for discussion with them later, she added.
“We have more hospitalizations in Canada per month related to alcohol comparatively to heart disease, and we still don’t throw the dollars and the evidence-based approaches into alcohol. We need to do a better job, and that is the whole purpose, I think, of these guidelines.”
The guideline document, co-developed by the Canadian Research Initiative in Substance Misuse and the BC Centre on Substance Use, says doctors could discuss ways that patients can cut back, prescribe medication, or refer people to get help with safely withdrawing from alcohol.
It also urges clinicians, including nurse practitioners, to avoid using terms such as “alcohol abuse” to reduce stigma, introduce the topic of alcohol use in a conversational way and to ask for patients’ consent before posing screening questions to foster trust. An example includes asking: “How does alcohol fit into your life?”
Poulin said there is ongoing stigma around addiction, including in the medical profession, and many doctors do not know they can prescribe medications, including naltrexone, acamprosate and disulfiram, to curb alcohol cravings.
A study published in July in the journal Addiction by researchers at the University of British Columbia and the BC Centre on Substance Use says that between 2015 and 2019, fewer than one quarter of people in the province who met the criteria for alcohol use disorder were prescribed medications. It notes less than five per cent of patients with a moderate to severe addiction received medications for the minimum recommended time of three months.
Lindsay Sutherland Boal of Toronto said talking about her “dangerous” heavy drinking helped her realize she wasn’t alone in her daily battle with booze. She decided to stop drinking on Jan. 24, 2020, after downing two bottles of wine the night before.
The latest guideline is a valuable tool to help people start conversations about drinking for the sake of their health, she said.
“People who overdrink do not know that their (general practitioner) can help them. They don’t know that it’s dangerous, oftentimes, not to talk to them because of the withdrawal,” Sutherland Boal said of debilitating symptoms such as a rapid heart rate and sweating from abruptly quitting alcohol.
“We’re afraid that we are either somebody with no problem at all or we’re totally on the other end of the spectrum and a full-blown alcoholic,” she said.
“The majority of people, when asked how much they drink, they lie because they don’t want their GP to think they’re an alcoholic.”
Sutherland Boal, who launched a group called She Walks in January 2022 to support women like her through online gatherings and walking events, said having the freedom to talk openly about alcohol helps to destigmatize a major societal issue.
“I got sober by walking and talking. I had to start talking. But I couldn’t walk very far because I was so overweight and so out of shape and my body was falling apart,” said Sutherland Boal, who added that ditching alcohol helped her get physically fit as she started paying more attention to her health and well-being.
Dr. Peter Butt, a recently retired general practitioner with a specialty in addiction medicine, said patients who seek care for insomnia, depression and anxiety should be asked about alcohol use because all of those conditions could be related to booze, especially among binge drinkers.
“It’s about their relationship with alcohol, what they get out of it, what’s problematic and their interest in pursuing different options to address it,” said Butt, associate professor in the department of family medicine at the University of Saskatchewan.
“Broadening the conversation is important, normalizing the conversation is important,” said Butt, who also co-chaired the expert panel that developed Canada’s low-risk alcohol guidance, released in January.
“Why should the conversation be more fraught around alcohol than it is around tobacco or cannabis or anything else? We should have regular conversations around substance use to monitor it and see if people are running into difficulty and where they’re at with regards to perhaps changing their level of use, or maybe stopping it altogether.”
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