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“A mother takes her 16 year old daughter to the GP's surgery as a consequence of her coming home very drunk the night before. She is genuinely concerned for her daughter's welfare, as this has happened quite a few times in recent months. She would like the GP to give her daughter a serious talk on the dangers of excessive alcohol consumption.”
Binge drinking accounts for up to 33,000 deaths in the United Kingdom every year, with the NHS spending costs of more than £164 million treating conditions related to alcohol abuse. 1 Alcohol is used as a means of relaxation, to socially bring groups of people together, and on average roughly making up 10% of one's caloric intake, thus making it a popular nutrient in a diet. As I investigate this scenario, I am going to consider the physiological and physical effects of alcohol consumption on the body, also looking at the social problems that can occur with binge drinking. Furthermore, I will describe key aspects of doctor/patient communication in the scenario given.
Physiological Effects on the Body
One of the main chemicals found in alcohol, which results in liver damage is the organic molecule ethanol (C2H5OH). It is both lipid and water soluble, making its way into the body by passive diffusion. 2 Approximately 0-5% enters the gastric mucosal of the upper gastrointestinal tract, such as the tongue, mouth and oesophagus, leaving the rest to enter via the blood. From this, 2-10% of ethanol is excreted by the lungs and kidneys, with the rest being metabolised by the liver for energy. 2 The liver receives this vast amount via the hepatic portal vein, which transports blood from the digestive system to the liver. This is why excessive alcohol consumption usually leads to the liver being the first site of damage.
Ethanol is metabolised by the body by the alcohol dehydrogenase pathway. 2 3 Firstly the enzyme, alcohol dehydrogenase, is used to convert ethanol into acetaldehyde in the cytosol, with NAD+ being reduced to NADH. 2 It is then converted into acetate by the enzyme, acetaldehyde dehydrogenase, which occurs in the mitochondria and also reduces NAD+. Ethanol also goes through cellular processing, which occurs in the endoplasmic reticulum of hepatocytes cells by the microsomal ethanol oxidising system (MEOS). This is where NADPH is oxidised into NADP+ due to the P450 mixed function oxidase enzyme, also creating water as a by-product. 2
Copious alcohol consumption can cause liver damage consequently leading to problems. Examples to acute problems are the inhibition of fatty acid oxidation and stimulation of triglyceride production leading to a fatty liver, lactic acidosis and hypoglycaemia. All this occurs because of an increase in the NADH/NAD+ ratio due to the metabolism of ethanol taking up all the carriers. 2-4 Fatty liver occurs when a high NADH/NAD+ ratio inhibits cycles of β-oxidation, which instead of metabolising the fats, re-esterifies them into triacylglycerol, which accumulate in the liver and ultimately cause fatty liver. 2 As the levels of NAD+ are low and subsequently cannot carry many electrons during glycolysis, pyruvate is forced to convert to lactate which quickly builds up and results in lactic acidosis. The high NADH/NAD+ ratio causes the lactate dehydrogenase equilibrium to shift, meaning that there is less gluconeogenesis, and hence the cause of hypoglycaemia. 2
Chronic alcohol abuse can generate free radicals and form an accumulation of the toxic acetaldehyde. This can induce hepatitis, which can lead to scarring of the liver (liver fibrosis), and eventually ending up with cirrhosis, where the growth of connective tissue destroys the hepatocytes and causes hepatic failure and death.2
Physical Effects on the Body
Ethanol is a depressant, and can act on the nervous system in numerous ways. It can stimulate the release of the inhibitory antagonistic neurotransmitter, GABA, to which it binds to certain receptors at synapses. 5 This means that the number of action potentials that would be sent through the nerves would decrease. This would then lead to physical, behavioural changes due to the depressant acting in the brain, such as reduced inhibitions where drinkers would participate in activities that they would not normally partake in, for example sexual activity and illegal drug use. 6 7 The lack of muscle control would also be associated with alcohol due to impaired motor functions, with the GABA neurotransmitters taking responsibility. Examples of symptoms would be slurred speech, impaired judgements, and poor coordination consequently leading to falls and accidents. 6 7
Ethanol also inhibits the neurotransmitter glutamate, which is found in the hypothalamus used for memory and learning. An inhibition of this would cause memory blackouts and confusion, due to the depression of the brains functions. 6-8
Although alcohol can be beneficial to the heart in moderation, such as reducing cardiovascular disease, 9 excessive alcohol consumption could in fact reverse the benefits. Despite increasing the amount of HDL (high density lipoprotein) cholesterol, excessive consumption can lead to hypertension.9 This is linked with vasodilation of blood vessels located in the skin leading to heat loss, even though it may seem to the drinker that they are warm.
Alcohol can also affect the digestive system. Ethanol can cause the increase of gastrin secretion in the stomach. This can cause vomiting and nausea, and with chronic consumption may lead to the formation of ulcers.
Social Effects of Alcohol Consumption
A study in Britain showed that people aged 22-58 use binge drinking as a way of socialising and easing the stress of daily life hassles. 10 Binge drinking is the consumption of an excessive amount of alcohol within a short space of time. 11 A definition of an excessive amount would be on average, 3-4 units for men, and 2-3 for women daily. 11 12 Nowadays, binge drinking has started to be seen as a socially acceptable activity in today's youth, with peer pressure being a culprit to allow teenagers to feel more adult and socially accepted into their group.
There are many social consequences that can result from binge drinking. It accounts for 20-30% of all accidents.11 The most prevalent of these is injuries are mainly traffic related ones, due to the alcohol affecting the person's thought processing, reaction times and coordination. 13 Injuries can also occur from alcohol fuelled violence and aggressive behaviour. 11 14 Half of all violent crimes are linked with alcohol, as a factor in 30% of sexual offences, 33% of burglaries and 50% of street crimes, not to forget a third of domestic violence incidents. 11 12 Every year, 5000-10000 people die each year from excessive drinking. 12 Heavy drinking is also responsible for 5-65% of suicide attempts, with 15-25% of them actually being successful. 11 12 All details of injuries can be found on table 1 which looks at acute alcohol related injuries to the general adults population in North America and Australia. 13
Alcohol can also increase the chances of risky sexual encounters such as unprotected sex, due to reduced inhibitions. Sources show that 40% of 13-14 year olds became pregnant after their first sexual encounter under the influence of alcohol. 12 These teenagers may also contract sexually transmitted diseases by ignoring contraception when intoxicated. Risky behaviour of adolescents may also lead to the experimentation of drug use, possibly starting off with legal substances such as alcohol and then moving onto illegal drugs such as cannabis and heroine.
Teenagers are mostly forced through peer pressure and what they see on television, to not only consume alcohol, but to binge drink. As they are not responsible enough to know their limits, it can be extremely hazardous to their health and could possibly kill them. They are then brought to hospitals which is an unnecessary cost to the NHS.
Key Aspects of Doctor/Patient Communication
The GMC states that relationships with patients are, “based on openness, trust and good communication [and] will enable [oneself] to work in partnership with [one's] patients to address their individual needs”. 15 Research shows that communication is essential in working out the diagnosis of a problem, 16 and if no relationship is established between the doctor and the patient, then a breakdown in trust and rapport may occur.
In our case, the minor is a 16 year old girl. She is therefore presumed competent enough to make her own decisions and given the right to consent to treatment. 17 The girl's mother is also present in the consultation and has brought her daughter along to give her a “talk” from an expert, rather than a parent to try and talk some sense into her.
Firstly, the doctor should try and make the girl feel as comfortable as possible, so that she is relaxed and comfortable enough to talk to the doctor. Other approachable measures that should be taken into account are: the doctor's body language, i.e. an open posture and making sure eye contact is at an equal level, leaning towards the patient, and also the arrangement of the furniture in the room, such as having chairs at right angles to each other or formally sitting behind a desk. 18
Good verbal communication skills are also needed for the consultation to work. Asking open ended questions to avoid answers being concise, understanding views from the patient, and obtaining expectations and concerns from the mother can help the doctor figure out the reason for their visit and the outcome they are expecting. Using this information can hopefully establish some sort of communication between the mother and daughter and also build up trust between them. Taking an empathetic approach will show the girl that the doctor is trying to understand how she feels, and make her feel that she is on the same level as him/her.
If the consultation is not going anywhere, it may be best for the doctor to have separate consultations with the mother and the daughter. As the girl is 16, she has a right to confidentiality and can ask for the mother to leave. The doctor must respect this decision and also realise that the daughter might be more open towards them when she is alone.
Alcohol is a potent drug that can affect the body in many ways; in moderation it is seen as beneficial to one's health, but when consumed to the point of intoxication can cause many problems to the person, being physically, mentally and socially. Nowadays, binge drinking is seen as a socially acceptable activity with friends, so the number of accidents and incidents related to alcohol has risen. These social problems can be small and minor such as having an argument with friends or family, or losing personal property on a night out. This can also extend to the other end of the spectrum, where the person starts experimenting with drugs or is having unprotected sex. There is also the risk of alcohol fuelled violence and accidents causing harm to the person.
Communication is key with a 16 year old girl who may see binge drinking as the normal thing to do at her age. A doctor must be able to listen to her and build a good rapport with her so that the consultation will not break down, therefore allowing the patient to trust the doctor and confide in them.