Cases/Smoking, Alcohol and Substance Misuse

Bus Driver Asks for Help to Break His Habit of Heavy Drinking — Free SCA Practice Case

Bus driver asks for help to break his habit of heavy drinking

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Robert Davies

Age

48 years

Consultation Type

Video

Age

48 (DOB: 12/04/1978)

Situation

Telephone or Video Consultation.

Reason for Encounter

"Patient booked a routine telephone appointment. Triage note states: 'I need help to stop drinking. I want to go cold turkey today.'"

Medical Records

●PMH: Essential Hypertension, Obesity (BMI 32).
●Medications: Ramipril 10mg OD.
●Occupation: Public Transport (Bus Driver).
●Allergies: NKDA.

Recent Notes

●Last seen 18 months ago for a routine hypertension review. BP was 145/90. LFTs normal at that time.

Patient Script

For the friend playing the patient role

Character Overview: You are Robert, a 48-year-old municipal bus driver. You have been drinking heavily for the past two years following a difficult divorce. Your alcohol intake has spiraled out of control. You are currently drinking one full bottle of vodka (70cl) every single evening. You have realized you are physically dependent. Every morning you wake up sweating, intensely nauseous, and with severe hand tremors. The Critical Secret: To stop the morning shakes so you can grip the steering wheel of the bus, you have started having a "livener" (a large glass of vodka) at 5:00 AM before your 6:00 AM bus shift. You are terrified of killing someone on the road, which has prompted you to call the GP today. You want to pour all the alcohol down the sink and stop "cold turkey" immediately. You are desperate for medical help to stop drinking, but you are absolutely terrified of losing your job and your pension. You will not volunteer the morning drinking or the fact that you drive the bus under the influence unless the doctor specifically enquires about withdrawal symptoms in the morning or asks about your work schedule.

ICE — Ideas, Concerns, Expectations

●
Ideas: You think the drinking has become a physical addiction — you know your body now needs the alcohol because of the shaking and sweating every morning. You don't really understand why you can't just stop, but you know something has changed in your body that means you can't function without it anymore.
●
Concerns: Your biggest fear is killing someone on the road while driving under the influence — that is what has finally pushed you to call. Beyond that, you are terrified of losing your Group 2 license, your job, your pension, and your house. You are also privately worried about what the alcohol might be doing to your body — you've noticed you've put on weight and you feel generally unwell — but the driving fear is what dominates today.
●
Expectations: You want the doctor to help you stop drinking safely, ideally starting today. You are hoping for some kind of medication or plan that lets you quit without anyone at work finding out. You want reassurance that you can get through this.

(The patient does not raise ICE unprompted — these perspectives surface only when the candidate directly explores the patient's ideas, concerns, or expectations.)

Consultation Flow & Responses:

●The Opening:
●If the doctor asks an open question: "Good morning, Doctor. Look, I'll get straight to the point. My drinking has gotten completely out of hand. I'm drinking a bottle of vodka a night. I've decided today is the day. I want to pour it all away and go cold turkey, but I know I might need some support."
●Data Gathering (The Layers):
●Layer 1: Quantifying the Addiction & Dependency:
●If asked about the amount: "A 70cl bottle of vodka. Every single night, without fail."
●If asked about withdrawal symptoms (Shakes/Sweats/Morning Drinking): "Yes, the mornings are the worst. I wake up drenched in sweat, and my hands shake so badly I can barely hold a cup of tea. I've had to start having a glass of vodka first thing in the morning just to steady my hands so I can go to work."
●Layer 2: The Occupational Risk (The Public Safety Trap):
●If the doctor asks about your job/driving: "I'm still driving the bus, yes. That's why I'm calling. I had that morning vodka today before my shift, and I just realized I could kill someone. I'm off shift tomorrow, so I want to stop tonight."
●Layer 3: Exploring the Resistance (ICE & DVLA):
●If the doctor informs you that you must stop driving and notify the employer/DVLA: Reaction (Highly Defensive & Panicked): "Whoa, hold on! You can't tell them! If you tell the DVLA, I lose my Group 2 license. I lose my job, my pension, my house! I told you in confidence! I'm stopping today anyway, so there's no risk anymore."

If Asked — Medical History and Medications

●
If asked about blood pressure or hypertension: "Yeah, I've got high blood pressure. I was told about it a couple of years ago. I take a tablet for it every morning — Ramipril, I think it's called. I haven't had it checked in ages though. I was supposed to go back for a review but I kept putting it off."
●
If asked about the Ramipril specifically or whether he takes it regularly: "I do take it most days, but if I'm honest, I sometimes forget — especially if I've had a rough night. I couldn't even tell you what dose it is."
●
If asked about weight or BMI: "I know I've put on a lot of weight. I used to be quite fit — played five-a-side and all that. But since the divorce I just eat rubbish, drink every night, and I've ballooned. The doctor mentioned my weight last time I was in."
●
If asked about liver function tests or blood tests: "I had some bloods done last time I saw the GP — that was about 18 months ago. They said everything was fine at the time, but that was before it got this bad. I dread to think what they'd show now."
●
If asked about the last GP visit: "It was about a year and a half ago. Just a blood pressure check. They said the pressure was still a bit high but nothing to worry about. I haven't been back since."
●
If asked about allergies: "No, no allergies to anything that I know of."

Social History and Lifestyle Impact

●
Occupation and daily life context: Robert works full-time as a municipal bus driver on early shifts, typically starting at 6:00 AM. Before the divorce two years ago, he was active and sociable — played five-a-side football with mates, went to the gym occasionally, and was involved in his kids' school activities. Since the divorce, he lives alone in a rented flat. He sees his two children (aged 12 and 14) every other weekend, but has been cancelling recently because he doesn't want them to see him in this state.
●
Lifestyle impact of the condition: The drinking has consumed his entire evening routine. He gets home from his shift, sits in front of the television, and drinks a full bottle of vodka until he passes out. He has stopped cooking — lives on takeaways and microwave meals. He has completely withdrawn from friends and stopped all exercise. He is increasingly isolated and barely leaves the flat outside of work. The mornings are a physical ordeal — he describes waking drenched in sweat with severe nausea and shaking hands, barely able to function until the morning vodka steadies him. He has started dreading work, not because of the job itself, but because he knows he is driving impaired and the fear of causing an accident is constant.

(This context is volunteered naturally in conversation — Robert is open about how bad things have become once he starts talking, though the morning drinking and driving detail only emerge if specifically asked.)

If Asked — Associated Symptoms

●
If asked about seizures or fits: "No, I've never had a fit or a seizure. But I do get this horrible shaky feeling every morning — it's like my whole body is vibrating."
●
If asked about hallucinations or seeing/hearing things: "No, nothing like that. I mean, sometimes when I'm really rough in the morning I feel a bit spaced out, but I've never seen or heard things that aren't there."
●
If asked about confusion or memory blackouts: "I do lose track of evenings sometimes. I'll wake up and not remember going to bed. But during the day I'm fine — well, once the shakes settle."
●
If asked about abdominal pain or stomach problems: "I get a dull ache up here sometimes (gestures to right upper abdomen), but nothing terrible. My stomach's not great in general — I feel sick most mornings and I've gone off my food."
●
If asked about vomiting or vomiting blood: "I've been sick a few times in the morning, yeah. Just bile, nothing with blood in it."
●
If asked about yellowing of skin or eyes (jaundice): "No, I don't think so. Nobody's said anything and I haven't noticed anything yellow."
●
If asked about swollen ankles or legs: "No, nothing like that."
●
If asked about chest pain or palpitations: "No chest pain. Sometimes my heart races a bit in the morning when I'm feeling rough, but it settles down."
●
If asked about mood or depression: "Yeah, I'm pretty low to be honest. I don't enjoy anything anymore. I just drink and sleep. But I'm not — I'm not thinking of doing anything stupid, if that's what you mean. The kids keep me going."
●
If asked about suicidal thoughts specifically: "No, genuinely not. I feel miserable, but I'd never do that to the kids. I just want to get better."
●
If asked about sleep: "Terrible. I pass out from the vodka but I wake up at 3 or 4 in the morning drenched in sweat and I can't get back to sleep. Then I'm exhausted all day."
●
If asked about appetite or eating: "I've completely lost my appetite. I barely eat a proper meal. Living on junk food and takeaways, but even those I don't really fancy anymore."
●
If asked about bruising or bleeding easily: "No, not that I've noticed."
●
If asked about tingling or numbness in hands or feet: "Actually, yeah — I do get a bit of tingling in my feet sometimes, especially at night. I just assumed it was the way I was sitting."
●
If asked about previous attempts to stop or cut down: "I've tried to cut down a few times. I managed to go two days without drinking about three months ago, but the shaking and sweating were so bad I caved. That's when I realised I couldn't do this on my own."

Negotiation & Collaborative Management Plan:

●If the Doctor agrees you can stop "cold turkey":
●Reaction: "Brilliant, I'll pour it down the sink now. Thank you." (Candidate critically fails for permitting abrupt cessation in a physically dependent patient, risking fatal seizures/Delirium Tremens).
●If the Doctor addresses the medical risk but ignores the DVLA/Driving risk:
●Reaction: "Okay, so I shouldn't stop suddenly. I'll slowly cut down over the week while I keep working." (Candidate critically fails for permitting a severely intoxicated patient to continue driving a public bus).
●If the Doctor firmly navigates both the Medical and Medicolegal boundaries:
●Reaction: "So stopping suddenly could give me a seizure? I didn't know that. But Doctor, please, you cannot report me to the DVLA. If I sign a piece of paper right now swearing I won't drive the bus tomorrow, will you keep this between us?"
●Final Resolution (If the doctor stands firm on GMC duty):
●Reaction: Resigned and defeated, but accepting. "You're right. I know you're right. I shouldn't be behind the wheel. I'll call my manager and tell him I'm sick, and I'll contact the DVLA. Please just help me get off this stuff."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 24 indicators checked+0−0

Positive (0/12)

Negative (0/12)

Domain 3: Relating to Others

0 / 10 indicators checked+0−0

Positive (0/5)

Negative (0/5)

Clinical Learning Points

The Pharmacology of Alcohol Withdrawal

●The Clinical Danger: Alcohol is a central nervous system depressant that enhances GABA-mediated inhibition and suppresses glutamate-mediated excitation. With chronic heavy use, the brain compensates by downregulating GABA receptors and upregulating NMDA glutamate receptors.
●The "Cold Turkey" Trap: Abrupt cessation in a physically dependent patient removes the exogenous GABAergic effect while the upregulated glutamatergic system remains unopposed. The resulting neuronal hyper-excitability drives tachycardia, hypertension, tremor, diaphoresis, hallucinations, withdrawal seizures, and Delirium Tremens (DTs). Untreated DTs carries a mortality of approximately 5–10%.
●The Practical Directive: It is counterintuitive but correct — a severely dependent patient presenting in active withdrawal must be advised to maintain a controlled, steady alcohol intake until a medically supervised detoxification can be arranged. Instructing him to stop immediately risks a life-threatening seizure before specialist care is in place.
●Recognising Physical Dependence: Morning eye-opener drinking, severe tremor, diaphoresis, and nausea on waking, prior withdrawal symptoms on attempted cessation, and blackouts are the hallmarks of physical dependence — not simply harmful or hazardous drinking. This distinction determines the entire management pathway.

Inpatient vs Community Detoxification — Choosing the Right Setting

●NICE CG115 provides clear criteria for considering inpatient or residential detoxification over a community-based programme.
●Inpatient detox should be considered when the patient: lives alone without an adequate support network; has a history of previous withdrawal seizures or DTs; is drinking more than approximately 30 units per day; has significant comorbid psychiatric or physical illness; or has failed a previous community detox attempt.
●Robert meets at least two criteria: he lives alone with no support network and is drinking approximately 35 units per night. A community detox — where an unwitnessed seizure could be fatal — is therefore not automatically the appropriate pathway. This must be explicitly considered and discussed with the patient before making the referral decision.
●The referral pathway: Urgent same-day or next-day referral to the local Community Drug and Alcohol Service (CDAS, e.g. CGL, Turning Point) for triage and detox setting assessment. The specialist team, not the GP, makes the final inpatient/community determination — but the GP must identify the concern and communicate it in the referral.

Assisted Withdrawal Pharmacology — Chlordiazepoxide Reducing Regimen

●Benzodiazepines are the first-line treatment for medically assisted alcohol withdrawal per NICE CG115. They work by substituting GABAergic activity, preventing the neuronal hyper-excitability of abrupt cessation.
●Chlordiazepoxide is the preferred agent in the UK for community and inpatient detox due to its long half-life (providing smoother symptom control) and lower misuse potential compared to diazepam.
●The regimen is typically a fixed-dose reducing schedule over 7–10 days, titrated to withdrawal severity. Initiation and titration are specialist-led; the GP's role is safe referral and interim management (maintaining alcohol intake), not independent prescribing of a reducing regimen without specialist oversight.
●Do not prescribe chlordiazepoxide independently for a patient of this severity without specialist input — this is a NICE CG115 recommendation for patients drinking more than 15 units/day with physical dependence.

DVLA Regulations: Group 1 vs Group 2 Licences

●Group 1 (Cars and Motorcycles): A patient with alcohol dependence must cease driving, notify the DVLA, and demonstrate a period of 1 year of abstinence with normalised blood markers before the licence can be reinstated.
●Group 2 (Lorries and Buses — HGV/PCV): The threshold is significantly higher. A bus driver with established physical alcohol dependence will have their licence revoked. Reinstatement requires a minimum of 3 years of abstinence (or 1 year for confirmed misuse without established dependence), normal LFTs, GGT, and MCV, and an independent medical assessment. The occupational consequences are catastrophic, which explains Robert's intense resistance.
●The immediate action: Regardless of the longer-term licence outcome, Robert must stop driving today — not when detox is arranged, not when he has cut down. Driving a public service vehicle while impaired by alcohol or in withdrawal is an immediate and ongoing risk to third-party safety.

GMC Duty to Disclose and the Confidentiality Framework

●The principle: Patient confidentiality is a core GMC duty, but it is not absolute. Where there is a serious, ongoing, and identifiable risk of death or serious harm to a third party, disclosure in the public interest is not only permitted — it may be obligatory.
●
The correct sequence (GMC guidance):
1. ●Advise the patient to stop driving and explain why.
2. ●Encourage self-disclosure — ask the patient to notify the DVLA and their employer themselves. Make clear this is the preferred route.
3. ●Inform the patient of your intent — if they refuse to act, tell them clearly that you will contact the DVLA medical adviser yourself, because the public safety risk overrides confidentiality in this case.
4. ●Act — contact the DVLA medical adviser if the patient will not self-disclose and the risk of continued driving is real and imminent.
●Do not skip steps: Disclosing without first attempting persuasion and informing the patient of your intent is not the correct sequence. Equally, accepting a verbal promise to "stop tomorrow" when the patient has been driving impaired today is not sufficient.
●Document everything: Record the conversation, the advice given, the patient's response, and any disclosure actions taken.

Wernicke's Encephalopathy — Thiamine Prophylaxis (NICE CG100)

●The mechanism: Chronic heavy alcohol use causes severe thiamine (Vitamin B1) deficiency through poor dietary intake, impaired gastrointestinal absorption, and reduced hepatic storage.
●Wernicke's Encephalopathy presents with the classic triad of confusion, ataxia, and ophthalmoplegia — though all three are rarely present simultaneously. Without treatment, it progresses to irreversible Korsakoff syndrome (anterograde and retrograde amnesia).
●Peripheral tingling — as Robert reports in his feet — may indicate early alcoholic peripheral neuropathy, another consequence of thiamine and B-vitamin deficiency, and reinforces the urgency of supplementation.
●NICE CG100 recommendation for community management: Oral thiamine 100mg three times daily (not 50mg twice daily — this is a common underdosing error). Also prescribe Vitamin B Co-Strong tablets to address the broader B-vitamin deficiency.
●Inpatient note: If there is any clinical concern about Wernicke's encephalopathy (acute confusion, ataxia, or nystagmus), high-dose parenteral thiamine (Pabrinex) is indicated in secondary care — oral thiamine absorption is unreliable in this context.

Hypertension and Blood Test Review

●Alcohol as a cause of hypertension: Heavy alcohol consumption is a well-recognised and reversible cause of secondary hypertension. Robert's BP was 145/90 at his last review 18 months ago — prior to the escalation in his drinking. Addressing the alcohol excess is likely to produce a meaningful reduction in blood pressure.
●Urgent bloods required: LFTs (including GGT — a sensitive marker of recent heavy use and hepatocellular stress), FBC (MCV elevated in chronic heavy use), U&Es, and a fasting glucose. These results will also inform the safety of any pharmacological decisions.
●Ramipril review: Once Robert is sober and the detox process is complete, his blood pressure should be formally reassessed. If BP normalises, a dose reduction or cessation of ramipril may be appropriate. Conversely, poorly controlled BP in the interim will need active management.

Relapse Prevention Post-Detox (NICE TA115)

●Detoxification alone carries a very high relapse rate. NICE TA115 recommends offering pharmacological relapse prevention to patients with alcohol dependence who have successfully completed assisted withdrawal.
●Acamprosate (first-line): Reduces alcohol craving by modulating glutamate receptor activity. Started immediately after detox. No hepatic metabolism, making it suitable even with LFT abnormalities.
●Naltrexone (first-line alternative): An opioid receptor antagonist that reduces the rewarding effects of alcohol. Contraindicated in patients taking opioids; caution if significant hepatic impairment.
●Disulfiram (specialist-initiated third-line): Creates an aversive reaction to alcohol. Requires motivated, supervised patients and is generally initiated by specialist alcohol services rather than in primary care.
●Psychological support: Cognitive Behavioural Therapy (CBT) and motivational enhancement therapy are recommended alongside pharmacological relapse prevention. These are typically delivered through the community alcohol team.

Comorbid Depression — Timing of Treatment

●Heavy alcohol use and depression are closely interlinked — alcohol is a CNS depressant, and sustained heavy use produces or worsens depressive symptoms independent of any pre-existing mood disorder.
●Key principle: Do not commence antidepressants during active alcohol dependence. It is not possible to diagnose or effectively treat a depressive disorder while the patient is drinking heavily. The mood often improves significantly with sobriety alone.
●The correct approach: Acknowledge the depression, plan active follow-up for mood reassessment 4 weeks after achieving sobriety, and initiate antidepressant therapy at that point if clinically indicated. Psychological support through the community alcohol team can begin concurrently.
●Safeguarding note: Robert reports no suicidal ideation and states his children keep him going — but mood and suicide risk must be explicitly screened and documented at every contact during this period.

Safeguarding — Children Affected by Parental Alcohol Dependence

●Robert has two children aged 12 and 14. He has been progressively cancelling contact visits because he does not want them to see him in his current state. This is a safeguarding consideration that the GP must acknowledge.
●Consider: Whether the children's welfare is being affected by his alcohol dependency — including whether the other parent or wider family are aware of the situation, and whether the children are receiving appropriate care and support.
●Action if concerned: A safeguarding referral to children's social care should be considered if there is evidence that the children are at risk of harm or neglect as a result of the parental alcohol misuse. At minimum, the children's welfare should be documented as part of the management plan and followed up.

Free MRCGP SCA practice case for GP registrars covering Bus Driver Asks for Help to Break His Habit of Heavy Drinking — Smoking, Alcohol and Substance Misuse. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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