30. MEDICAL WORK-UP

This should be considered for all patients who misuse alcohol. It follows Section 47 on Map 1 .

If a person is misusing alcohol over an extended period of time, there is an increasing risk of damage to his/her body. A general physical examination and blood workup can identify physical issues that should be addressed.

30a. Making the Referral

How you make the referral depends on person’s the stage of change relative to alcohol issues [ Section 47 ].

If the person is in precontemplation or denial, then a focus on alcohol will seem off-base. In this case, the idea of getting a medical workup to assess possible damage from drinking may be resisted. If you express concern, the patient may go to please you or prove you wrong about the effects of alcohol for him/her. Alternatively, you may be able to refer him/her to a physician for another reason (e.g.: to a urologist or gynecologist if there are sexual problems), then ask the physician to look for physical signs of alcohol misuse and to order appropriate tests as a check for damage from drinking. The results can be then discussed with the patient, and may motivate change. This approach has the disadvantage of deceiving the patient, which is a risky approach to anyone.

In the other stages, when the person recognizes a need for change but may or may not have begun to take action, a medical checkup can be presented as a way of gathering relevant information. In contemplation and preparation stages, the information can be used to assess the physical urgency of treating the patient’s alcohol use. In the action stage, the issue is more about what action to take to facilitate recovery.

30b. What to Request

TESTS
You may request for the physician to order

• a blood chemistry profile, including liver function. Liver complications are common outcomes of excessive drinking, both in the short and long term. The other is a shotgun approach to see what issues the person might have.
• the amylace level. This indicates whether the pancreas is working normally or not. Pancreatitis is a common problem for alcoholics.
• CBC (blood profile), with differential. Is this different from the other?
• a blood alcohol content test, using blood or urine.

A pulse over 100 beats/minute, temperature over 100°, and diastolic BP approaching 100 are all common reactions of withdrawal. A patient who attempts to hide his/her physiological dependence by not drinking the day before the medical appointment might reveal an alcohol involvement indirectly in this way.

Once a patient is diagnosed as suffering from alcoholism, a treating physician should screen for malnutrition. This could include testing for blood folate levels. Treatment might include a proper diet and vitamin B12 injections.

INFORMATION FOR THE PHYSICIAN

In addition, there are things you should tell the physician, if you are aware of them:

• any a history of gastrointestinal bleeding, gastritis, pancreatitis, hepatitis, strokes, jaundice, acid reflux, weight loss, blackouts, DT’s, any alcohol withdrawal symptoms
• sedative or hypnotic use
• any information about past injuries, accidents and diseases
• any history of head trauma while drinking, or if the patient has in any way become unconscious, e.g., through a fight, car accident, or falling down

30c. Medications

There is often a temptation to prescribe medications for a patient who has psychological symptoms in addition to an alcohol problem, to help the person deal with anxiety, depression, etc.

If this seems likely, a psychiatric referral should be made at this time, because the clinical picture may be ambiguous and the medications may interact with alcohol or other drugs the patient is already using. A psychiatrist, especially if forewarned by the referring psychotherapist, is more likely to be familiar with both alcohol treatment and the actions of psychotropic medications than a primary care physician.

In general, psychotropic drugs should be avoided at this point if possible, because

• alcohol may interfere with action of some drugs
• alcohol may compound with other medications, at times leading to increased physical and psychological risks
• alcohol may cloud the diagnostic picture, leading to a risk of overmedicating or medicating for the wrong disorder

If, after a period of several weeks’ abstinence, a patient’s psychological issues remain serious, the issue of medications can be re-visited and another referral made. [See Adjunctive Care, Section 19 ]

30d. Using Medical Information

For a patient in the precontemplation or contemplation stage, a greater awareness of the effects of drinking on the body may be motivating, to modify his/her drinking and to change his/her life in other ways. Providing a patient with information about the negative consequences of drinking may detract from the perceived benefits. In itself, it may not be enough to get the person to stop, but it may increase his/her discomfort enough to contribute toward that goal.

For a patient in the preparation or action stage, the medical report may provide direct suggestions for changes in behavior or additional medical interventions that may be necessary.