November 28, 2011

Taking a good social history from patients involves asking about alcohol consumption. Drinking has many wide-ranging health implications. But as a rheumatologist, my concerns regarding my patient’s drinking habits are fairly narrow. Alcohol consumption plays havoc with a gouty patient’s hyperuricemia. Alcohol also doesn’t mix well with many rheumatoid arthritis medications such as methotrexate or leflunomide.

Some of my patients just can’t imagine life without beers or booze. As far as I can recall, the only patients in this elite category are men. If there are women in my practice who have similar drinking habits, they have escaped my notice thus far and have flown under my clinical radar.

A few times a year, I have a conversation that goes something like this: I tell the patient that their RA is poorly controlled with their current medications. The implications of this are obvious, but I spell them out anyway: "If we don’t do more to control your arthritis, you will have worsening problems with pain, joint damage, and possibly disability. I could put you on more effective treatment, but you would have to stop drinking alcohol, or at the very least, cut way back on your drinking." A lot of these guys look at me as if I had asked them to do something completely impossible or unreasonable.

One afternoon in clinic, my curiosity got the better of me, and I asked one of my 12 beer a day guys how he allotted his daily beers. I had the naivete to ask him if he drank four beers with breakfast, four beers with lunch, and another four beers with dinner. He gave me a slightly offended look, and I knew I had put my foot in my mouth. With wounded dignity he explained that he only drank in the evenings! What could I have been thinking?

Class and health insurance figure heavily in these situations. Sometimes, my RA patients who won’t swear off their beloved six packs can bypass MTX and go directly to a biologic medication. Many insurance companies will deny coverage for these expensive wonder drugs if the patient hasn’t tried MTX first. Since MTX is much less expensive and quite helpful, I think the insurance company has a legitimate gripe if the doctor tries to bypass a trial of MTX.

One of my patients with a fancy job in state government was able to start a biologic after I told the insurance company that he had tried some other medications that didn’t work, and I felt that MTX was contraindicated for him! I guess if the insurance company asked me the reason I felt MTX was contraindicated, I could have written down ICD 9 code V69.8 (beer drinker). Unfortunately, health insurance is usually not so understanding and benevolent for my other patients in similar situations.

I have another patient with active RA who refuses to quit drinking. He is an unemployed school janitor with marginal insurance benefits and he won’t be able to start any expensive medications. I have told him bluntly on several occasions that his drinking made it impossible for me to effectively treat his arthritis, but we remain in a standoff.

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