"I see you went to Captain Morgan for a second opinion"

Patient addiction is a delicate minefield for docs to tread. GPs beware:
you're the first line of defence

By Julia Cyboran

Charles Krucheck had been seeing the same GP for close to 20 years. He'd show up at the office every May for his annual physical. All in all he's been quite healthy, his cholesterol was a little on the high side, but nothing that would worry his doc. So it came as a shock when his latest blood work turned up with elevated GGPT (glutaryl transaminase) levels, symptoms usually associated with years of regular alcohol abuse.

Although he wasn't crazy about the idea of confronting a long-time patient about a pretty prickly subject, the doc called Mr Krucheck back into the office to ask a him few tough questions. Not surprisingly, he was presented with a wall of silence. Mr Krucheck denied any alcohol problems and suggested that the test results must be wrong. But that afternoon, after returning from the doctor's office, he poured himself the first of many vodkas and kept on drinking until he was numb.

ADDICTION ON THE BREATH
Sadly, this case isn't uncommon. "With alcohol it's pretty difficult," says Dr David Yue, an Edmonton family physician. "Patients rarely tell you. One of the only ways to pick up on the problem is if you smell alcohol on their breath." And getting a whiff of booze is rare seeing as most alcoholics (and other addicts) have mastered the art of hiding their vice, so asking questions � and knowing how to interpret the answers � is vital. "Whatever the patient tells me, I multiply it by two," says Dr Yue.

Dr Bruce Ballon, a psychiatrist at the Centre for Addiction and Mental Health in Toronto, believes that GPs should be asking addiction-related questions early on. Routine screenings can help pick up on warning signs and also make it easier to broach the subject when odd results, like Mr Kruchek's, show up in the blood work. If a doc always refers back to these types of questions, the patient won't feel like they're being singled out.

Dr Ballon also explains that even though some GPs have basic training in addiction or mental health problems they aren't always sure how to approach the patient. "The key is to not be judgmental," stresses Dr Ballon, "and to educate the patient."

CONFRONT VS CONVERSe
"I let them know I'm aware of the problem," says Dr Yue. "I then give them the option of going through rehab. I basically tell them what needs to be done to improve their health." But if the patient ignores the advice or refuses to seek help, a doc can be stuck somewhere between a rock and a hard place. "If they aren't looking after themselves," says Dr Yue, "I don't have time to look after them."

If a patient feels like their doctor is haranguing or nagging them, they might go and seek help elsewhere. "If the patient doesn't come back to see me," says Dr Yue, "it usually means that they've found another GP who will treat them without touching on their addiction problems."

But for those who are ready to face their problems, there are options. "If there are intense addiction issues, it's preferable to refer to an addiction centre," says Dr Ballon. "Twelve-step programs do work, but no one particular treatment is for everyone."

Another point that Dr Ballon raises is the importance of treating the underlying problem. "It's a question of the chicken and the egg," he says. "Did the patient start drinking because they were depressed or vice versa?" For instance with alcohol, which is a depressant, a patient may have started hitting the bottle to ease their blues. On the other hand, the alcohol itself could be the root of their depression.

A QUICKER FIX
Treating addiction with medication is still controversial. Some doctors are more inclined to write up a script immediately, while others are wary, seeing it as nothing more than a quick fix. "Medications should be looked at as augmenting treatment or treating that underlying problem," says Dr Ballon. "Some docs will say, 'I can't treat the depression until the patient is off the alcohol or drugs,' but that isn't always the case."

Once any underlying mental health conditions have been ruled out a doc can proceed with prescribing, although a quick check with a local pharmacist is advised to help avoid any negative interactions. For instance the addiction drug, bupropion (Zyban) should never be given to alcoholics because it can lead to seizures.

Naltrexone, a drug that's been used to help opiate addictions, is now emerging as a possible therapy for alcoholism. A recent presentation at the annual meeting of the American Psychiatric Association pointed to its benefits. The drug basically blocks the pleasurable feeling of alcohol, explains Dr Ballon, adding that it replaces disulfiram (Antabuse), which was commonly prescribed but is now only available in special institutions. The only problem with naltrexone is that it won't work for alcoholics who drink to knock themselves out.

In the end, treatment should be about the patient. "You have to have a holistic approach," says Dr Ballon. "Meds are a part of the treatment, but it's not the be all end all."