A personal view from a GP/Occupational Physician with a practice in the treatment of drugs & alcohol addiction.
What is it about drugs & alcohol?
Mankind is drawn towards intoxication. Edward Slingerland’s new book Drunk investigates human’s enduring need for mind altering substances, particularly our relationship with alcohol, and comes to the startling conclusion that far from being merely a pleasure or a vice, alcohol might be vital to civilization itself1. The first recorded wine was brewed over 6,000 years ago and there is archaeological evidence of consumption long before that.
Alcohol is the only legally sanctioned mind-altering substance for general use in most industrialised societies and its’ consumption positively encouraged in western culture. A visit to any card shop will reveal that over half the humorous birthday cards, aimed at women in particular, extol the virtues of alcohol intoxication as a necessity for celebrating the day.
Are we heading for a ‘lockdown liver’ pandemic?
As a portfolio GP and Occupational Physician with an extended role in the treatment of drugs & alcohol addiction, I have seen hundreds of people impacted by the covid pandemic. The story given by one of my patients to the BBC in August 20202 was typical of many other service users at Steps Together Rehab, one of many residential drugs & alcohol treatment centres in the UK.
Chris worked as a Salesman and described how his relationship with alcohol changed during the first lockdown: “I suppose I’ve always been a social drinker – I was never within the recommended limits, and so yeah, I used to enjoy a drink, sometimes a little bit more than I should, as a lot of people do. I was in a good place before lockdown, I was keeping fit, I was swimming five days a week, I was doing well at work and I was in a good mindset to be honest.”
Chris goes on to describe how the isolation and uncertainty affected his relationship towards dependency. “Although I wanted to cut down and stop at that point, I wasn’t in control of that. And that was the frightening part. I’ve never been like that in my life and I had to admit that to myself. I was drinking very early in the morning to stop withdrawal symptoms”.
Chris’ story is typical of so many people we’ve admitted for alcohol detox. When listening to their stories, these are people who, a few weeks previously, were functioning well, holding down jobs, living normal day-to-day lives. Within a few weeks of lockdown, they’d become dependent alcohol drinkers. One patient described it perfectly when telling me that lockdown had made, “every night was a Friday night”. Other factors contributing to increased drinking were feelings of job insecurity and general uncertainty for the future. Even those who were furloughed, or not isolated, had their children at home, getting involved in home schooling and “there was just that need for a stress-buster every day.”
Chris recognised that he needed help and, following medical detoxification, has been abstinent for several months. He was lucky that his employers supported him throughout his fall into dependency and allowed him the time to attend residential detoxification and rehabilitation. He is now back to full-time work and thriving. Others aren’t so fortunate. I would estimate that more than 50% of the clients I see in residential detoxification have lost their work as a result of their addiction.
Alcohol related deaths are rising
Across the UK, the number of alcohol related deaths rose by almost twenty percent in 2020-2021, the highest year on year increase since records began in 2001. (79.8%) were caused by alcoholic liver disease. The Covid Pandemic has been a significant factor in this increase and the main increase is working age people (45-60 years old)3. In other words, people at risk of alcohol related liver disease have been drinking more during the covid pandemic.
As early as May 2020, the British Medical Journal revealed that alcohol consumption had increased during the first covid lockdown4. Although the total sales of alcohol actually fell during the early stages of the pandemic, the volume of home sales increased by up to 67%. Many people’s alcohol consumption changed in this period, some reducing their consumption. However, a pattern has emerged that people who were already risky drinkers (AUDIT-C score ≥ 5) were drinking more and the number of risky drinkers increased from 25% of adults between April 2019 and February 2020, compared with 38% during lockdown in April 20205. Another fact that could influence the burden of liver disease, is that older age groups tend to be those drinking more, a long-term trend that continued during the covid pandemic6.
There is a mixed pattern when looking at drug misuse in the working age population. It is estimated that around 70% of people addicted to drugs are in employment. It may surprise many readers that drug misuse overall is fairly static, or even falling for crack, cocaine and ecstasy. However, drug-related deaths have been rising. Death by drug-related poisoning was 60.9% higher in 2020 than in 2010. The rates of drug-misuse death peaks among those born in the 1970s, with the highest rate in those aged 45 to 49 years. This so-called ‘generation X’ are far more likely abuse heroin than any other age-group.
Are there drugs we’re missing on occupational health screens?
The main 3 drugs of abuse to watch out for are that in my experience or not typically considered in workplace screening: ketamine, pregabalin and synthetic cannabinoids.
Ketamine. There is a rapid increase in younger adults misusing ketamine. Although the numbers are relatively low, the numbers entering treatment with ketamine problems is 3.5 times higher than it was in 20157 . Ketamine abuse can result in severe mental health deterioration, increased the risk injury and life-changing urological complications
Pregabalin. Since April 2019, pregabalin has been categorised as a class-C controlled substance. Although very helpful in the management of neuropathic pain and anxiety, it can give a high similar to that of benzodiazepines. It is often used alongside opioids or diazepam and I’ve come across a few cases where opioid users take this to minimise withdrawal symptoms, in order to achieve a negative urine opioid screen at work. I would recommend an occupational health department to screen for this substance where workplace intoxication is suspected.
Synthetic cannabinoids. (commonly known as mamba/spice). These used to be classified as ‘legal-highs’ but since 2016 are banned for sale by the Psychoactive Substances Act. This is typically a drug used by the homeless and prisoners due to the low price and difficulty in urine screening. The chemical formulations are continually changing, making urine screens a moving target. I’m not aware of any evidence of the impact at the workplace, but these drugs are worth bearing in mind where intoxication workplace at the workplace is suspected.
Hair or nail testing: The future of screening?
I would predict that the major advance in screening at the workplace will be an increased use of hair or nail testing, particularly for workers in safety critical roles. A recent addition to my occupational medicine practice has been to provide support to pilots whose hair testing has revealed drugs or alcohol misuse. It strikes me that the occupational health community, and particularly the DVLA, should consider such testing for LGV and public transport drivers. The advantages and disadvantages of hair or nail testing are laid out in table 1
Psychoactive substance (drugs and alcohol) testing for pilots is only a recent requirement following the introduction of new regulations by European aviation regulatory bodies that now require all pilots to be tested prior to employment and randomly throughout the course of that employment. This provides a 3-month history of drug & alcohol use.
David Whiffin, MD of OdiliaClark, an organisation that provides a testing and rehabilitation service said, “In the world of aviation, safety is paramount, and at the heart of an organisations safety management system are the people within the organisation. Part of the testing programme is to ensure that staff are at their best, both mentally and physically. We believe that no employee wants to come to work under the influence of a psychoactive substance, so when we find something, we have questions to ask around education and mental wellbeing. When problems are found, for many clients it’s the start of a journey with that employee and depending on what is found a range of support services can be introduced. Not only to support the employee but most importantly to give the employer the confidence that the employee is mentally and physically fit to carry out their role.”
Where can healthcare professionals signpost those at risk?
If a healthcare professional is keen for a patient to reflect on hazardous drinking, there is likely to be a group that appeals to the patient’s specific life goals and aspirations. A good starting point would be Alcohol Change UK https://alcoholchange.org.uk/ or the Drinkaware Trust https://www.drinkaware.co.uk/. As with any addiction or substance misuse, I would also encourage someone to reflect on their consumption before making the change. ‘Alcohol Know your limits’ is a superb downloadable guide produced by the NHS https://tinyurl.com/y57uafwd and the NHS live well site https://www.nhs.uk/live-well/alcohol-support/ could be an alternative starting point towards change.
The numbers seeking support through local drugs & alcohol treatment services reduced during the covid pandemic. Yet, analytics from Alcohol UK showed significant spikes of people accessing the ‘get help now’ section of their website during the lockdowns8.
Self-help communities are emerging, with many moving away from ‘alcohol as an illness’ approach towards a move to dissociate fun, hedonism and relaxation from drugs or alcohol. This approach could be helpful to risky, but non-dependent drinkers. For example, Club Soda9 promotes a mindfulness-based approach to reducing alcohol and is a champion for the growth of alcohol-free drinks for people who want to continue their love of beer, wine and spirits. The Sober Girl Society reaches out to women who want ‘all of the fun, none of the alcohol!’10
In summary, the landscape of mild-altering substance use in the working age population is changing and we are likely to see more problems with alcohol-related problems at the workplace in the next few years, particularly in middle-aged workers. Several new substances are emerging in younger age groups that are not typically considered or tested in most workplaces. However, I would predict that the growth of hair or nail testing will continue and, if adopted more widely, should lead to safer workplaces, and targeted opportunities for lifestyle change and rehabilitation.
1Edward Slingerland, Drunk: How We Sipped, Danced, and Stumbled Our Way to Civilization, Little, Brown August 2021, (ISBN: 9780316453387)
2https://www.bbc.co.uk/news/health-53807908 (accessed 3rd June 2022)
3ONS (accessed 3rd June 2022)
4Covid-19 and alcohol—a dangerous cocktail, BMJ 2020; 369 https://doi.org/10.1136/bmj.m1987. (accessed 3rd June 2022)
5Jackson, S. E., Garnett, C., Shahab, L., Oldham, M., and Brown, J. (2020) Association of the COVID-19 lockdown with smoking, drinking and attempts to quit in England: an analysis of 2019–20 data. Addiction, https://doi.org/10.1111/add.15295. (accessed 3rd June 2022)
6ONS. Quarterly alcohol specific deaths in England and Wales: 2001 to 2019 registrations and Quarter 1 (Jan to Mar) to Quarter 3 (July to Sept) 2020 provisional registrations. February 2021. ONS (accessed September 30th 2021)
7Adult substance misuse treatment statistics 2020 to 2021: report – GOV.UK (www.gov.uk) accessed 27th May 2022
8https://alcoholchange.org.uk/help-and-support/ (accessed 3rd June 2022)
9https://joinclubsoda.com/(accessed 3rd June 2022)
Rob Hampton is a GP and Occupational Physician. His portfolio includes roles in drugs & alcohol treatment, health & work tribunals, and medico-legal assessments. He has worked in collaboration with several Occupational Health Nurse Advisors in recent years to assist in sickness absence medicals for complex cases and ill health retirement assessments.
A member of the BMA Occupational Medicine Committee and founder of the SOM GP Interest Group. He currently leads an NHS project to improve report writing skills for GPs involved with medico-legal assessments.
His preferred mode of working is to work collaboratively with Occupational Health Nurse Advisors and is always ready to receive referrals for work in London or the Midlands.
He can be contacted through firstname.lastname@example.org or www.rhhmedical.com