Junaid Ahmad Bhatti  ( Sunnybrook Research Institute )
Sharef Danho  ( Institute for Clinical Evaluative Sciences )
Muhammad Shahid  ( University of Toronto, Toronto, ON, M4N 3M5, CANADA )

 Alcohol use is a pervasive globally, especially in the Western world, where four out of five people consume alcohol regularly ¹. Since alcohol use impairs judgment in the short-term and affects many body systems in the long-term, many countries and international organizations recommend low-risk drinking guidelines (1-3). However, still a significant proportion of population consumes over these limits; e.g., in the United States, about 15% of the population consumes above recommended limits². These consumption patterns are not without consequences3. The World Health Organization (WHO) estimates that 3.3 million people die each year from alcohol use, accounting for more than 5% of the global burden of disease1. By some estimates, 1 in 10 deaths amongst working age adults can be attributed to alcohol². In the United States alone, the annual health care and economic costs of alcohol related disability equates to $250 billion³. Alcohol has wide ranging health effects involving many different body systems. These include several cancers especially of the gastrointestinal tract, liver cirrhosis, pancreatitis, bone marrow suppression, and a higher risk of infections such as tuberculosis. While low levels of alcohol intake have been shown to have protective cardiovascular qualities in some studies, there is also evidence to suggest that alcohol is still associated with atrial fibrillation and hemorrhagic stroke1. Alcohol has also been linked to anxiety, depression, temper issues, risky behaviours, social problems, road traffic injuries, and suicide⁴. There are parts of the world where alcohol use is prohibited, for example, most Muslim majority countries in the Middle-East including Pakistan have strict regulations regarding the sale and consumption of alcohol at public venues. In Pakistan, the sixth most populous nation of the world, most of these restrictions were part of the Hudood ordinance from 1979 that banned sales of alcohol to Muslim residents⁵. The current laws recognize the rights of non-Muslims, who still have access to alcohol under special permits. Despite strict laws, it seems that alcohol misuse has become a significant problem in Pakistan. It is common for newspapers to show spikes in alcohol-intoxicationrelated deaths around festivities. There are reports of an illicit, underground alcohol manufacturing and sales market. This practice is common in countries where alcohol is prohibited and leads consumers to use homemade drinks that pose a unique poison danger 1.In response, authorities often publicize the destruction of large consignments of alcohol in the media. There are now a growing number of private medical facilities that offer services for alcohol addiction in Pakistan’s larger cities including Islamabad, Karachi, and Lahore. Taken together, alcohol misuse may be more prevalent in Pakistan than currently perceived. Around 4,000 – 5,000 physicians graduate from Pakistani medical and dental schools each year and according to Pakistan’s Medical and Dental Council there are 189,157 registered members in Pakistan as of December 31, 2017⁶. While most physicians are trained in obtaining a medical history for smoking and other illicit substances, they receive little training in identifying and screening for signs of alcohol misuse. These deficiencies may make it challenging for physicians to provide the needed medical care for patients. Conversely, in Western countries, it is recommended that all adults over the age of 18, regardless of their medical presentation, be screenedfor unhealthy alcohol use in the primary care setting⁷. Patients with problematic alcohol use may initially present with symptoms of gastritis, such as abdominal discomfort, nausea, vomiting, bloating, or loss of appetite⁴. There may be signs of alcohol withdrawal, including tremor, agitation, anxiety, or tachycardia. The physical exam may yield no findings, to mild and nonspecific symptoms such as hypertension, or even include signs of signs of liver disease such as ascites, peripheral edema, spider nevi, palmar erythema, jaundice, hair loss, digital clubbing, etc. A physician should also look for any signs of repeated trauma or injuries that may result from episodes of intoxication. Finally, the presence of certain psychiatric disorders could also be associated with unhealthy alcohol use,  including depressive symptoms, anxiety, or other substance use including opioids, cocaine, amphetamines, or cannabis8. While these signs and symptoms are not completely predictive of unhealthy alcohol use, these may warrant further investigation and a conversation into a patient’s drinking habits. There are many simple questionnaires available to physicians to assess alcohol related hazards in patients. For instance, the Alcohol Use Disorders Identification Test (AUDIT) is a 10 item questionnaire and is the most validated screening method for unhealthy drinking. A
score above 8 on AUDIT is considered positive. A briefer, almost equally as effective version of the AUDIT can also
be used, the AUDIT-C, which includes only three questions:

● How often do you have a drink containing alcohol?
● How many drinks containing alcohol do you have on a typical day when you are drinking?
● How often do you have six or more drinks on one occasion?

A score of 4 or more in men and 3 or more out of 12 in women is considered positive for unhealthy drinking⁹. Another commonly used screening tool is the CAGE questionnaire¹⁰.

● Have you ever felt you should cut down on your drinking?
● Have people annoyed you by criticizing your drinking?
● Have you ever felt bad or guilty about your drinking?
● Have you ever taken a drink first thing in the morning (eye-opener) to steady your nerves or get rid of a hangover?

A positive response to any one of these questions should raise concerns to the physicians about the potential for unhealthy alcohol use¹¹. It is also always important to ascertain whether any immediate family members suffered or currently suffer from any substance abuse, as a positive history may raise a red flag for screening since people can be genetically predispositioned to substance abuse¹². At the minimum, physicians should be asking if their patients drink any alcohol and how often they are doing so. For women and all patients over 65, risky drinking is defined as 10 or more units per week or more than 3 units in a day. For men under 65, 14 or more units per week or more than 4 units in a day. In the United States, one unit consists of 5 ounces of wine, or 12 ounces of beer, or 1.5 ounces of spirits¹³..A physician should also ask about binge drinking, defined as 3 or more drinks for women and 4 or more for men on a single occasion. This is important as binge drinking has been associated with poor health outcomes including increased risk of cardiovascular disease and traumatic injuries¹⁴. During the encounter, physicians must pay attention to  non-verbal cues – of guilt or embarrassment, because if there are social or legal consequences for consuming alcohol, patients may be less willing to share information¹⁵. As such, a physician must be empathic, nonjudgemental, and encouraging while telling the patient that this must be difficult for them and commending them for agreeing to talk about the subject. Remind the patient that the conversation is confidential – a patient must not fear being reported to any legal system or authorities for drinking alcohol¬ – and that the purpose of these questions is to gain a better understanding of their health habits so that they can receive the medical care they need. Furthermore, some societies feel it is unfair for persons who abuse alcohol to use medical resources because they are making a conscious decision to drink¹⁶. It is imperative for physician to reiterate to the patient that unhealthy alcohol use is associated with many factors out of their control, such as genetics. However, the burden of responsibility to change must eventually fall on the patient, which is why it is important for the physician to see whether they understand the gravity of the situation and educate accordingly. As well, how a patient interacts with their social environment can
influence their health, especially in the context of unhealthy alcohol use. For example, is the patient in an occupation that involves a possibility of danger to themselves or others? This may be the case if a patient operates heavy machinery or is frequently driving a vehicle. These patients have a higher likelihood of sustaining unintentional injuries such as falls, road
traffic collisions, and being involved in violent situations that can also harm other individuals¹⁷. Therefore, in the settings of alcohol prohibition, physicians have an important role to assess preemptively the alcohol misuse risks in their patients
and to guide them to the appropriate addiction treatment services.

Competing interests: None

References

1. Poznyak V, Rekve D, editors. Global status report on alcohol and health 2014. [Internet] Geneva, Switzerland: WHO Press; 2014 [cited 2018 December 10]. Available from: https://www.who.int/substance_abuse/publications/alcohol_2 014/en/
2. Stahre M, Roeber J, Kanny D, Brewer RD, Zhang X. Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States. Prev Chronic Dis 2014;11:E109. doi: 10.5888/pcd11.130293.
3. Harwood H. Updating estimates of the economic costs of alcohol abuse in the United States: Estimates, update methods, and data. [Internet] Bethesda, MD: The National Institute on Alcohol Abuse and Alcoholism; 2000. [Cited 2018 December 10]
Available from: https://pubs.niaaa.nih.gov/publications/economic-2000/
4. Fiellin DA, Reid MC, O'Connor PG. Screening for alcohol problems in primary care: a systematic review. Arch Intern Med 2000;160:1977-89.
5. Wasti AS. The Hudood Laws of Pakistan: a social and legal misfit in today's society. Dalhousie J Legal Stud 2003;12:63-95.
6. Pakistan Council for Science and Technology. Women in Health. [Internet] Islamabad: Pakistan Council for Science and Technology; 2018 [cited 2018 December 18] Available from: https://www.pcst.org.pk/wst/wst_whea.php
7. U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med 2004;140:554-6.
8. O'connor PG, Schottenfeld RS. Patients with alcohol problems. N Engl J Med 1998;338:592-602.
9. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 1998;158:1789-95.
10. De Oliveira JB, Kerr-Corrêa F, Lima MC, Bertolote JM, Santos JL. Validity of alcohol screening instruments in general population gender studies: an analytical review. Curr Drug Abuse Rev 2014;7:59-65.
11. Maisto SA, Saitz R. Alcohol use disorders: screening and diagnosis. Am J Addict 2003;12(S1):s12-s25.
12. Grant BF, Dawson DA, Stinson FS, Chou PS, Kay W, Pickering R. The alcohol use disorder and associated disabilities interview schedule-IV (AUDADIS-IV): reliability of alcohol consumption, tobacco use, family history of depression and psychiatric
diagnostic modules in a general population sample. Drug Alcohol Depend 2003;71:7-16.
13. National Institute on Alcohol Abuse and Alcoholism. What is a standard drink? [Internet] Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism; 2009 [cited 2018 December 10]. Available from: https://www.niaaa.nih.gov/alcoholhealth/ overview-alcohol-consumption/what-standard-drink
14. Willenbring ML, Massey SH, Gardner MB. Helping patients who drink too much: an evidence-based guide for primary care clinicians. Am Fam Physician 2009;80:44-50.
15. Chartier KG, Vaeth PA, Caetano R. Focus on: ethnicity and the social and health harms from drinking. Alcohol Res 2013;35:229-37.
16. Tjønneland A, Thomsen BL, Stripp C, Christensen J, Overvad K, Mellemkjær L, et al. Alcohol intake, drinking patterns and risk of postmenopausal breast cancer in Denmark: a prospective cohort study. Cancer Causes Control 2003;14:277-84.
17. Zeisser C, Stockwell TR, Chikritzhs T, Cherpitel C, Ye Y, Gardner C. A systematic review and meta-analysis of alcohol consumption and injury risk as a function of study design and recall period. Alcohol Clin Exp Res 2013;37:E1-8. doi: 10.1111/j.1530-0277.2012.01919.x.