What I wish every doctor knew about alcoholism

I have really struggled to complete anything over the last week, after experiencing a bit of “success” with my last post.  I’ve written lots, I now have 6 posts in varying shades of incompleteness, which I have added a paragraph or two to each time I’ve sat down to write, which has been most days.  And I have been grappling with what was well over 2000 words on “what is alcoholism” – and, you know, this is a blog not some essay competition.  So this is an attempt to break it down, and I am intending to do a series of 3, the 2nd being “What I wish ever counsellor knew about alcoholism” and “What I wish every minister knew about alcoholism”.  (Like all good genies (and preachers) I get 3 wishes!)  This post is fairly medicalised, assumes a certain degree of knowledge, and is less centred on faith than my usual writing (apart from that I find it impossible to think without it).

 

1. Alcoholics are shape shifters

Once you’ve been addicted to one thing, you are at massively higher risk of becoming addicted to something else, and just because that something else is a prescription drug doesn’t lessen the agony and the damage it can go on to cause. The following should be given in my opinion with extreme caution and not without very solid indications: opiates; benzos; zopiclone and its friends; anything with sedating side effects eg. tri-cyclics, chorphenamine.  You get the idea.  I have met so many people who, sometimes in established recovery from alcohol, then became addicted to something else, and it was initially prescribed by a doctor.

Now, I’m not saying it’s the doctor’s fault that these people then went on to using the substance irresponsibly or switched to illicit drugs, but the doctor must take some responsibility.  AA is variable on how wisely it informs people about this – from the “take nothing” extreme to its ‘declining to comment on outside issues’ opposite. Addiction services can also be variable, and so the ‘it’s ok if it’s prescribed by a doctor’ myth pervades.

It comes down to whether we believe in Hippocrates, and his famous saying of “above all, do no harm”.  This isn’t an obvious harm, and it’s certainly not a glamorous bit of medicine.  It takes real guts though to see these people in all their humanity and do right by them, knowing that not only will they not thank you for it, they’ll probably give you a fair amount of grief for not giving them the sleepers they asked for.  Tough.  This is tough love time.  You might not think you trained all those years to sit and listen to some drunk berate you because you won’t give them any more painkillers for their gallstones but you know what?  You really did.

 

2. Just because there are “alcohol services” and “drugs workers” doesn’t mean you get to shirk responsibility for your patient.

Of course there are plenty of good doctors.  And it’s very significant too that alcoholics are mostly heartsinks, a pain in the neck to look after, and dash your hopes time and again. Smelly, full of tears of self pity, of everyone else’s failings, and in all their active addictive glory, I can understand it being very tempting to hand them over to the alcohol/drug service as soon as possible, and to hand them back whenever there is a problem, or change, or they go back to the drink or drugs.  This happened to me, it happened when I attended in crisis, and when I asked for disulfiram, and when I said I’d had a single night’s drinking, and when I had been sober for a while and was looking for counselling.  And I’d get reported to Social Services with each of those, too, but that’s a whole other post.  And maybe that’s the protocol – I’m sure each consultation could be defended, and maybe will be by my GP friends and readers.  But it felt like my own doctor would not engage with me, was not interested in or able to help me, and really disliked seeing me, actually.  I certainly came to dislike seeing him.  I felt he lacked the courage, or kindness, to engage with me, and when talking to my peers in treatment I know I was not alone.  I am reminded that Jesus said, ‘Truly I tell you, whatever you did not do for one of the least of these brothers and sisters of mine, you did not do for me.’ (Matthew 25v45).  We are called to remember our own humanity, to listen, and to have the guts, quite honestly, to go out on a limb for this difficult patient group – who feel as if they are ‘the least’ – and to treat them as the King.

 

3. Learn to self-soothe (healthily)

There is a much quoted phrase among students and doctors that “an alcoholic is someone who drinks more than their doctor”.  Like all good stereotypes, this has its feet in the truth, and doctors are indeed up there in the top 5 professions to have a problem with drink.  We all know someone who drinks to much, and it was admired, in my student years, to have been out at 2 dancing and on a ward round at 9, green with a hangover, but present nonetheless.  We think spectacularly incoherently about alcohol with respect to ourselves.  13% of people have a problem with unsafe alcohol use (WHO).  I believe it is a lack of learning to self-soothe in a healthy manner that means, by the time these hungover students are practising, alcohol seems to fulfil the need to take the pain and stress away, just for a little while.

I taught communication skills courses at Manchester Royal Infirmary for a while, and on an excellent full day course for final years there was a section for an informal discussion on ‘coping’.  Ironic, considering I was the one quietly not coping, and not telling anyone, but I think what I observed is valuable nonetheless – within a couple of minutes, someone would mention the benefits of sharing a bottle of wine, or a night with the lads in the pub.  By the time we finally get round to mentioning the need to learn to cope and not just hang on in hope that it will happen (and this is not being negative about Manchester – at least it’s in there, I don’t recall it being for us 10 years ago) the words drinking and coping have become almost synonymous.  It’s too late.  Whilst there were a few positive suggestions from students, and I taught that particular course a good number of times, I did feel they were often theoretical ideas, not something that had become a regular part of the student’s life and routine.

Jesus says in Luke 4v23, “Surely you will quote this proverb to me: ‘Physician, heal yourself!’”, where he is expecting the proverb to be used in mockery of him.  In treatment, both in the roughness of Birkenhead, and the privilege of Bayberry, I had my training thrown back at me.  “Isn’t there somewhere else you can go”, said Eileen*, leaving unsaid, “you’re just all wrong for here”. By normalizing it and laughing it off, we increase a culture of blame, secrecy and shame.  We are not superheroes and we cannot heal ourselves from alcoholism.  We need to change the culture.

 

I realise I have tried to sit both sides of the fence here – it remains impossible not to.  When it comes to identity, I count both highly on a list of what makes me who I am.  The one I am glad to be throwing a little further off each day, the other I hope to soonish step back into

 

*name changed to protect anonymity

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3 Responses to What I wish every doctor knew about alcoholism

  1. Alex says:

    Really thought provoking….will change my practice and ‘tolerance’ (if that is the right word?? Not sure what is?) towards alcoholics. Unfortunately, in central Cheshire, everything gets referred to alcohol services in terms of detox, but I really take on board the comments about changing one addiction to another, and my ‘safe sleeper’ amitrip (can never spell it!!) is probably best avoided. Big hugs, and please email me your 2000 words-would really help me understand it from the other perspective!
    Going for a coffee now-decaf of course!!! ;)

    • Sarah says:

      Well, we could include caffeine in the switching of addictions too (and don’t mention diet coke!) – but you have lots of experience and I don’t think there are any hard and fast rules. As you know I have had to – and with that extreme caution – personally take a couple of the drug classes mentioned. Not without some resistance and risk benefit analysis.
      I’m not sure there are safe sleepers. (Melatonin – unlicensed – got me back to normal after the 24 hour lights and sounds of ITU). But there is a whole load of things around sleep hygiene that people don’t do, because it takes time and effort and sacrifice – and I think they really work. Not what your average newly clean addict wants to hear though.

  2. Sarah says:

    I had my training thrown back at me. ”Isn’t there somewhere else you can go”, said Eileen*, leaving unsaid, “you’re just all wrong for here”
    Hi honey, lost it here, bit fascinated, doctor degree or not. Will use it with my lads. Thinking of you today as over a week since we coffeed and caked, must again soon, back in a few weeks. xxx

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