MEDICAL MATTERS:Is it time for doctors to use alcohol as a drug, asks MUIRIS HOUSTON
‘NOW, LET’S review your medication. Is five bottles of the Cabernet Sauvignon lasting a full month? Not quite, hmm . . . you should certainly get five days out of each bottle at one glass a day. There’s talk of bringing out a slightly bigger bottle for cardiovascular prevention, but until they do you’ll have to juggle a bit, I’m afraid. Will the larger bottle be available on the medical card? I’d be very surprised if it wasn’t . . . ”
A consultation from fantasy land? Or the gist of a routine encounter with your GP in the not too distant future? Has the time really come to prescribe alcohol as part of a comprehensive approach to preventing heart attacks and strokes?
The publication last month of two key papers in the British Medical Journal means doctors and other healthcare professionals must now decide whether to move from advising patients of the benefits of a mild to moderate intake of alcohol to a more prescriptive approach. But to do so will mean addressing wider societal fears about alcohol use and its risks.
Researchers from the University of Calgary, Harvard University and the University of Texas analysed some
63 studies that examined adults without known cardiovascular (CV) disease and that compared blood levels of specific biological markers associated with coronary heart disease (such as cholesterol) after alcohol use with biomarker levels after a period of no alcohol use.
They found a moderate intake of alcohol leads to increases in HDL-cholesterol (good cholesterol) and decreases in fibrinogen, factors associated with a lower risk of heart disease.
The findings suggest that the lower risk of heart disease observed among moderate drinkers is caused by the alcoholic beverage itself, and not by other associated lifestyle factors.
In a separate paper, the same authors examined some 84 prospective studies on the association between alcohol consumption and overall mortality from cardiovascular disease, as well as the incidence of and mortality from coronary heart disease, and incidence of and mortality from stroke.
They concluded that one to two standard drinks a day protects against cardiovascular mortality, and reduces both the risk of and death from coronary heart disease, while an intake of up to one drink per day protects against the occurrence of stroke.
Taken together, the two reports make a compelling case for alcohol as an actual cause of the reduced risk of cardiovascular disease which we have long associated with light to moderate drinking.
But the real challenge is what to do with the information? According to Dr William Ghali, the senior author of both pieces of research, there are two levels at which it needs to be considered: “One is, what does a doctor say to a patient in a clinical setting? And the second is, what do public health officials tell the public?”
In clinical practice, they contend, the evidence base supporting CV benefits from alcohol intake could be the basis for “counselling for selected patients to incorporate moderate amounts of alcohol into their diets to improve their coronary heart disease risk”.
But before that could happen, the strategy would have to be evaluated “in pragmatic clinical trials that assess the questions of optimal patient selection, compliance, risks, and benefits”.
Which is all very logical and correct. But public health experts will now have to grapple with sending out diametrically opposed messages on alcohol.
One will be its undoubted benefits, while the other will have to point out the risks to physical and psychological health that can be precipitated by an even moderate intake of wine and spirits. And we know how difficult it is to get simple public health messages across – how will they cope with a message as complex as this?
Meanwhile, for patients and their doctors in the privacy of the individual consultation, there is a potential pink elephant in the room. Do they wait for the trials Ghali refers to or should both drinkers and teetotallers be given prescriptive advice on how to use alcohol as a drug?