In my role as a general practice registrar, the past three years have been a steep learning curve. Juggling patient, practice and time demands, with the priority of providing medical assessment, advice and treatment, is an ongoing challenge. Initially, I felt awkward when asking patients about their drug and alcohol habits when they presented with seemingly unrelated issues. Over time, I have become increasingly confident in exploring the impact of patients’ lifestyles on their health.
Earlier this year, I reviewed a patient with a gardening injury. After attending to the immediate concerns, I gently steered the conversation to discuss the alcohol I could smell on his breath. He was surprised at my question and said he was in the habit of having several beers at lunch. He had injured himself soon after commencing his yard work that afternoon. In this case, addressing substance use was clearly important and needed consideration for my patient’s overall wellbeing; however, the health issues arising from drug and alcohol use are often more opaque.
The prevalence of substance use and its consequent morbidity and mortality make this issue particularly relevant to general practitioners (GPs). The 2013 National Drug Strategy Household Survey (NDSHS) found:1
18.2% of Australia’s population (over 14 years of age) drank alcohol at levels exceeding lifetime and single occasion risk guidelines.
15% of the same population had used illicit drugs in the prior 12 months.
Cannabis was the most commonly used illicit drug, with a reported lifetime use of 35% in the same population.
The non-medical use of pharmaceuticals in the prior 12 months was reported to be 4.7% of the same population.
In this edition of Australian Family Physician, Harrison and colleagues’ analysis of BEACH data show that men aged 45–64 years, Aboriginal and Torres Strait Islander peoples and those from disadvantaged socioeconomic areas have a high prevalence of chronic excessive alcohol consumption. The study also concludes that GPs are successfully incorporating the Department of Health clinical practice guidelines to treat chronic excessive alcohol consumption.2,3
We are fortunate in Australia to have well-developed guidelines, such as those by National Health and Medical Research Council (NHMRC).3 While specific guidelines are not available for cannabis, Copeland4 provides algorithms for assessment and intervention, and summarises current treatment options for cannabis use disorder and withdrawal.
The area of prescription medication misuse is an evolving area of concern, with rising prevalence. Monheit, Pietrzak and Hocking provide a summary of current abuse patterns and risks associated with drugs of dependence, and highlight strategies for reducing and managing prescription drug abuse.5 The ‘inherited patient’ is a particularly fraught area for management of drugs of dependence and Grinzi summarises an approach focusing on consideration of rational prescribing.6
My patient with the gardening injury has since been to see me, most recently about subfertility issues. We revisited his alcohol use – he had stopped his lunchtime beers, but he had been drinking more than four standard drinks several days a week and regularly used cannabis. Together, we made a plan about reducing his substance use, with regular review and ongoing education about the health effects of his lifestyle. These changes have seen him improve his overall health in preparation for becoming a father.
In Australia, using alcohol to relax, celebrate and socialise is very much part of our culture and ‘having a few at lunch’, as was the case for my patient, is not uncommon. During an interview in March 2016 about Australia’s binge drinking culture, Stephen Parnis, Vice President of the Australian Medical Association at the time, said:
We’re dealing with a cultural problem from 1788 where alcohol has been a core aspect of Australian life.7
The results from NDSHS indicate that the Australian population is increasingly using other drugs in a similar context. GPs are required to assess and manage drug abuse effectively and this task is difficult given the evident normalisation of such behaviour. While there is no single method to do this, the focus articles in this issue of AFP provide information to assist in the process. I hope you find these articles stimulating and, perhaps, a prompt to revisit this important area of patient care.
Rachel McDonald MBBS, BScBEng (Hons), PhD (BiomedEng) is a Publications Fellow at Australian Family Physician and a general practice registrar at Shepparton Medical Centre.