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Rapid Responses: Rapid Responses published:
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Collective Approach to tackling Alcohol Misuse
- Sujaa Mary Rajagopal Arokiadass (7 March 2008)
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Medication without consent or reason
- Michael A Parsons (8 March 2008)
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Sujaa Mary Rajagopal Arokiadass, Specialist Registrar in Forensic Psychiatry Department of Forensic Psychiatry, Runwell Hospital Sub Regional Medium Secure Unit, SS11 7XX
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I read with great interest the British Medical Association’s (BMA) recent report on Alcohol Misuse: tackling the UK epidemic - http://www.bma.org.uk/ap.nsf/Content/tacklingalcoholmisuse. As a higher trainee in forensic psychiatry with a special interest in substance misuse, I perceive on a daily basis the effects of alcohol misuse on physical, mental (Kessler et al, 1997) and societal health particularly criminal behaviour (http://www.homeoffice.gov.uk/crime-victims/reducing-crime/alcohol-related -crime/) There is evidence that the risk of offending increases under the influence of alcohol (www.crimereduction.homeoffice.gov.uk/drugsalcohol/drugsalcohol81.htm - 23k -). Drinking excessively can also make people become vulnerable victims of crime. Furthermore, it can precipitate or perpetuate comorbid illicit drug use with all the likely negative sequelae. The ICD 10 (World Health Organization International Classification Of Diseases 10th Revision Version) and the DSM 1V (The Diagnostic and Statistical Manual of Mental Disorders) have both attempted a classification on the mental and behavioural effects of alcohol use. However, it is difficult to attempt to bring all alcohol related problems under a single umbrella. Alcohol misuse is a pervasive problem that crosses the boundaries of medicine and psychiatry. The origins of excessive drinking appear to be multifactorial and bio- psycho- socio- culturo- political. The BMA in its report calls on the Government to show leadership and to implement a full range of effective control policies that will reduce the burden of alcohol misuse. This is important. However, effectively tackling alcohol misuse would mean a collective approach from both the Government and people from multidisciplinary backgrounds i.e., school teachers, parents, mental and physical health professionals, social workers, prison authorities, police, politicians, patients, Off licence shop owners, bar staff and the rest of the public as well. Sharing of responsibility seems to be the key. Alcohol is undoubtedly the favourite drug of the nation (Leaflet by the Royal College of Psychiatrists' Public Education Editorial Board, last updated: January 2008). However, there is significant stigma against the ‘alcoholic’ in the UK and the rest of the world. This plays a major role in determining people’s willingness to acknowledge the problem of excessive drinking or alcohol dependence. This in turn affects treatment seeking behaviour and subsequently compliance with ongoing treatment. Stigma also interferes with the effective rehabilitation of the ‘recovering alcoholic’ in the community. The BMA report recommends screening questionnaires to identify patients at risk of alcohol misuse. This may not be effective unless health care staff are universally trained specifically to elicit details pertaining to alcohol use. This is because most ‘alcoholics’ tend to be evasive and have difficulty admitting the exact amount of alcohol that they drink. The root of the problem is therefore more deep. Attempts at education and reducing stigma against the alcoholic is a way forward. The key recommendations in the BMA report namely higher taxes on alcohol, an end to irresponsible promotional offers and activities, standard labels providing information on guidelines for comparison and reducing the legal limit for the level of alcohol while driving, reducing opening hours of places selling alcohol can all help towards reducing the availability of alcohol and therefore alcohol misuse. However, it would be more difficult to influence change in individual choices in lifestyle (for example, higher costs may breed higher frequency of criminal behaviour) unless a change in attitude is made possible. Insight promotion comes through education. Ideally, this should start at home; continue in the school and throughout life. The BMA report is right in recognising and pointing out that there must be enough funding for the specific management of identified patients with alcohol related problems. This is very relevant given the current climate of never ending cuts in service provision. Enough funding would help to reduce the stress on healthcare staff and perceived helplessness among the revolving door patients and its counter transference on the professionals who often acknowledge the feeling of fighting a losing battle. References 1) BMA Report - Alcohol Misuse: tackling the UK epidemic (2008) http://www.bma.org.uk/ap.nsf/Content/tacklingalcoholmisuse 2) Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey R. C. Kessler, R. M. Crum, L. A. Warner, C. B. Nelson, J. Schulenberg and J. C. Anthony Department of Health Care Policy, Harvard Medical School, Boston, Mass, USA. Vol. 54 No. 4, April 1997 3) Alcohol-related crime http://www.homeoffice.gov.uk/crime- victims/reducing-crime/alcohol-related-crime/ (Sourced by the British Crime Survey 2006/07) 4) Drinking, Crime and Behaviour - Research Development and Statistics Directorate of the Home Office, UK, 1999/1998 Youth Lifestyles Survey Published: Feb 2003 www.crimereduction.homeoffice.gov.uk/drugsalcohol/drugsalcohol81.htm - 23k 5) Leaflet by the Royal College of Psychiatrists' Public Education Editorial Board, last updated: January 2008, http://www.rcpsych.ac.uk Competing interests: None declared |
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Michael A Parsons, Retired Lecturer Oxford and Cherwell College OX9 9RR
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The BMA's latest anti-drink presentation was an unintended warning against medicalising social problems.
Surely doctors agree that it is unethical to treat patients without their informed consent. This remains true even if the treatment is disguised as "public health" activity. The press conference showed how men are never more dangerous than when they reckon to be doing good, for then they lack all the normal restraints of conscience in dealing with the rest of us (a point that may explain the cruelty of some past medical practices). They rode rough-shod over the reasonable preferences of others,in pursuit of their millenial hopes.
Anyway the BMA case is weak at best. A range of social and personal harms complained of (bad driving, organ failures, youthful misbehaviour etc) occur in non-drinkers too, so alcohol is not a necessary factor there; and many (if not most) imbibers do not exhibit these results, so it is not a sufficient cause either. Attacking an indulgence enjoyed by people when it is neither the necessary nor the sufficient cause of the evils complained of is both silly and domineering. Even sillier is the suggestion that if moderate and law-abiding drinkers were made to pay more, this would somehow benefit youngsters who either do not pay at all, have plenty of money, or even steal their drink. At first sight it is the stuff of absurdity, but this latest scheme may turn out be no more than a dodge to avoid facing up to the weakness of current liberal enforcement procedures when it comes to detaining and re-training persistent offenders (especially young ones).
It is also futile: however much behaviour subsequently moves in the desired direction, our Goody-two-shoes will never relax their demands. You can already see this in the current treatment of car-driving. In spite of our excellent safety record, driving is attacked by ever more exactions and supervisions, when in fact the police (like the BMA)should be gratefully turning attention to greater dangers elsewhere. In the BMA's case hospital infections perhaps.
The cause of wrong-doing, after all, is the decision to commit it, not the means. The substitution of ether for alcohol would hardly be a blessing, would it?
Competing interests: None declared |
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