DGIM Generally Speaking

If we are not looking for it, alcohol use can sometimes slide along, unaddressed, for years. That is what Ms. D, a delightful 86-year-old lady I met as a trainee, taught me. After her primary care physician of over 40 years retired, she came in to see me with a debilitating peripheral neuropathy. After three visits and a workup for every other conceivable diagnosis, I finally called and asked her about alcohol use. “Do I drink alcohol? Well, yes, sure.” I still remember Jeopardy blaring on her TV in the background. “I usually have a drink before dinner and with dinner, and before bed too. My last doctor, he was always telling me to quit.” She showed me, unforgettably, that one can never deliver good care based on assumptions. 

MGH and the DGIM have recently made screening our patients for alcohol and substance use disorders a priority. With the leadership of Dr. Sarah Wakeman, medical director of the substance use disorders initiative, MGH began universal screening of all inpatients in 2014. Recently, prompts for annual alcohol and drug screening with the AUDIT-C and DAST-10 have appeared in our primary care Epic encounters, pushing us to address alcohol and substance use with every patient every year. 

One provision of the recently passed federal tax legislation will affect alcohol consumption and thus will directly affect the health of our patients. The “Craft Beverage Modernization and Tax Reform Act” cuts excise taxes on alcohol by about 20%, or $4.2 billion, over the next two years. Most of the savings will go to industry, but some of the cuts will be passed on to consumers resulting in lower prices for beer, wine, and hard liquors. 

There is considerable evidence that reducing taxes on alcohol leads to increased alcohol consumption, and therefore increased rates of alcohol-associated disease and injury. A 2010 systematic review published in the American Journal of Public Health concluded that “doubling the alcohol tax would reduce alcohol-related mortality by an average of 35%.”[1] The CDC presently assesses alcohol-related deaths at 88,000 per year, and Adam Looney, a health economist at the Brookings Institution estimates that this figure will increase by about 1,550 deaths in the coming years as prices drop and Americans drink more.[2] 

This grim projection places renewed importance on our department’s efforts to achieve universal annual screening for alcohol and substance use disorders. The first step, the one I wished I’d taken with Ms. D: we have to ask.

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Would you like to share a story from your DGIM experience here, or have a private consultation about a manuscript or about writing in general? Contact me at skoven@mgh.harvard.edu

[1] Alexander C. Wagenaar, Amy L. Tobler, Kelli A. Komro, The authors are with the Department of Epimiology and Health Policy Research and the Institute for Child Health Policy, College of Medicine, University of Florida, Gainesville. “Effects of Alcohol Tax and Price Policies on Morbidity and Mortality: A Systematic Review”, American Journal of Public Health 100, no. 11 (November 1, 2010): pp. 2270-2278.

[2]https://www.brookings.edu/research/measuring-the-loss-of-life-from-thesenates-tax-cuts-for-alcohol-producers/

Read more articles from the Winter 2018 edition of Generally Speaking