FRIDAY NIGHT TO Saturday was the most unattractive tour of duty in the psychiatric emergency room of the old mental hospital, keeping doctors and nurses cloistered while everyone else was enjoying weekend pleasures. Weekday shifts did not mess up weekends, so they were more desirable. From noon Saturday through the rest of the weekend, comp time was offered at twice the hours worked, so it quickly accumulated and offset some of the pain of missing out on weekend fun. But the Friday night tours really had no redeeming features. So it should come as no surprise that, being the youngest doctor on staff, I found myself assigned to quite a few of them.
It was one of those Friday nights. The night shift had just taken charge of the small psychiatric emergency room. They were a hardened crew, used to managing not only the patients, who could range from psychotic and violent to depressed and suicidal, but also the young physicians. The shift manager, a nurse in her late fifties with highlighted hair and a generous frame, was an imposing figure to doctors, nursing assistants, and patients alike. She could appear less than caring. “Hi Sven, is it you again?” she might say. “How about you and I chat about those people talking in your head? You know, if we talk for a while, I’m sure you will not need to come in tonight again.” But in fact she was not callous at all. She just knew that the patient with chronic schizophrenia would not get better by coming into the psychiatric emergency room, and that this patient’s distress could just as well be alleviated by someone listening for a while and then being firm and directive. Over the phone line she could masterfully pick out the patients who really needed to see us because their demons threatened to scare them off the edge of the cliff or for some other reason. “You’re in that much pain, huh? You know, sometimes life really is so painful it is amazing people can carry on. But you need to hold on. I promise, it will get better. I know it’s hard for you to believe right now, but take my word for it, I’ve seen this so many times before. It does get better eventually, you hear me? How about I just send out a car so you can come in and talk to our doctor? I have a really good one tonight. Then maybe you can stay with us and try to get your meds adjusted.” To this day I am humbled by how experienced nurses like her, with a phone line and a chart as their only source of information, were able to make these difficult calls. When I was much further along in my career, I decided I would give it a try myself, just for the experience. I ended up telling almost every patient who called to come in, flooding the emergency room beyond workable.
The shift manager treated us young doctors much the same way she treated the patients. “Sign here” was her most common comment to us, often without us ever having a chance to talk to the patient or even think about the order we were being asked to sign. Only when I had won her confidence did she start to tell me, one quiet night, about the crazy, inconsistent, or outright dangerous things she had seen done by physicians who were passing through her post on a rotation and could not wait to move on. She spoke passionately about how she viewed herself as an advocate for the patients, with an obligation to protect them from the whims of doctors who, most of the time, were en route to a career somewhere else.
That particular Friday night we received a desperate call from Eric’s wife. He was drinking again. Now, a common theme throughout this book is that relapse does not have to be a disaster. As I will discuss, it is an expected element of any chronic disorder such as addiction, much the way it is with hypertension, asthma, or diabetes. It should be approached with calmness, optimism, and a belief that something can be learned from each episode, helping the patient to better manage future challenges. But some cases are different, and I had an unpleasant feeling that Eric’s relapse was one of those. He was obese at a level that by itself put him at high risk for major medical complications, and he had an insulin-dependent diabetes that got more out of control with every new episode of drinking. After seeing many patients with catastrophic outcomes, I have learned that my gut feeling is worth paying attention to.
I had seen Eric a couple of times before. This was prior to the era of the modern alcoholism medications. For whatever it was worth, we had suggested that he take Antabuse, but we could not convince him that it would be helpful. At least I had managed to get him seen for a series of sessions by our wonderful social worker. Despite a rheumatoid arthritis that had turned her own hands into painfully twisted stumps—or maybe because of it—she was better than any of us at conveying hope and coaching change. Yet for all her charisma, talk therapy had not done much good in Eric’s case, just as it didn’t in too many others.
Because of his medical condition, I had a last resort that over several months had kept Eric out of trouble. In those days there was a law on the books that allowed involuntary admission for a patient who, because of ongoing drug or alcohol use, risked severe medical complications or death. Most physicians, I quickly learned, looked the other way rather than invoking that paragraph. They would perhaps consider it if they were dealing with a drug perceived as being really dangerous, such as heroin, abundant in our region. Alcohol problems, however, tended to be the subject of indifference at best.
But I was young and idealistic. After his latest admission, I had told Eric that if he continued to drink despite his diabetes, I would have to write the court papers that would have him locked up to save him from himself. His wife had accompanied him to that visit, and her relief was palpable. Finally someone was going to help. Eric had already told me I was one difficult guy, but he somehow still liked me. He knew I was serious, and he could not afford to be locked up to be dried out. He had a grocery store to run. I wrote a referral to a local clinic for regular checkups, made an agreement that his wife would contact me if it looked like he might be about to fall off the wagon, and parted ways with the couple. I did not hear from them for quite some time and came away with the impression that if I cared, and managed to stand firm, it was perhaps not so hard to do some good. So it was only appropriate that I was working the night, months later, when Eric’s wife called. She was crying but was able to convey the seriousness of the situation. Eric was drinking again and had stopped taking his insulin or, worse still, was taking it in a random manner. He had passed out a couple of times already, and it was difficult to know if it was because of low blood sugar, intoxication, or both. He took the phone when I asked to speak to him. Even though I could hear how slurred his speech was, he insisted that he was not drinking.
I asked him to get into a taxi and come in so that we could admit him, detox him, and try to get things on track again. He refused. I said we could send a taxi for him. No luck. After all, there was no need: he was not drinking. Finally I told Eric I would ask the police to bring him in for involuntary admission, said good-bye, and went on to fill out the paperwork.
The scene that followed a few hours later has stuck with me to this very day. The dimly lit corridor of the emergency room. The two police officers. Eric’s crying wife. And in the foreground, Eric himself, amazingly enough not at all upset with me. Quite the opposite. He was cheerfully waving to me and saying, “Don’t worry, doc. It’s all right. I only had a light beer with lunch, that’s all.” At the same time the nurse, from behind him and over his shoulder, was showing me his breath alcohol level—380 mg/dl, a level close to which a person without profound tolerance is at risk of arrested breathing resulting in death. Eric, meanwhile, managed to walk by his own devices, his large body seemingly only slightly off balance. When the officers left and Eric was being rolled off to the locked intake ward, he kept saying, “It’s OK, doc. Just a beer. It’s nothing.”
Eric was admitted that night and detoxed over the next week, but after that there was little else we could do. The immediate danger that justified the involuntary admission was over. We offered extended residential care, an expensive option we thought in those days was helpful but could choose only in select cases. He was not interested. He went home and died shortly afterward. I cannot remember whether it was a diabetic coma or something else that got him, but I do remember the feeling of being powerless that his wife and I shared after he was gone.
Sometime later, as I was crossing the campus for an all too rare lunch with my father, I looked at the bottom floor of the student apartment building and a sadness came over me. Since my first day of medical school, Eric’s grocery store had been a constant—the place students had gone to for milk, cheap noodles, and other essentials. Then there was nothing; groceries would no longer be sold there.
This was one of my early lessons about the destructive force of addiction, the limitlessness of denial, and the insufficiency of the tools medicine had placed at my disposal. Obviously, countless more lessons would follow. Maybe one reason this one stuck with me is that it freed me of some of my innocence and naïveté. But it also captured several elements from which a journey into the landscape of addiction should start, each of which we will revisit in detail along the way: that addiction makes people continue to use a drug even if they know it causes them severe harm and is likely ultimately to cost them their life. That nice people who might be perfectly able to contribute to society still may end up using drugs until they die. That the potential for denial, both from the patient and from everyone else, until it is too late exceeds most people’s imagination. That trying to talk the addict out of drug use is challenging at best. And that trying to force the person to quit, even if feasible, is not very helpful other than in the shortest of terms.
The story of my encounter with Eric also says something about a drug that may not receive the attention it merits. When I ask students what addictive drug they consider to be the most damaging, I get different answers. Some say heroin, particularly if they have paid attention to how deadly it can be for the individual overdosing.
1 Others say cocaine, which is widely associated with violent crime, ravaged inner cities, murderous cartels, and the whole war on drugs. Others still say crystal meth, which is more potent than cocaine and so should command considerable respect. Some, not entirely unreasonably, say nicotine, citing data such as those indicating that among people who have tried this drug, the proportion found to be addicted is higher than for any other addictive substance.
2Few students say that alcohol is the most damaging drug. Yet data from the World Health Organization show that among addictive drugs, the toll of death and disease caused by alcohol use is surpassed only by that caused by nicotine. And nicotine is a special case because it does not cause much harm itself. After all, we know that a skin patch that delivers nicotine is reasonably safe. It is instead the use of tobacco products that causes nicotine-associated harm. In that respect, alcohol addiction is much more similar to illicit drugs and causes more harm than any of those.
One way of calculating the harm associated with a condition, widely accepted across different areas of medicine, is to sum up the number of
quality-adjusted life years lost owing to that condition. If life expectancy is seventy years and someone dies at forty, clearly thirty years were lost, adjusted or not. But if someone instead dies at age sixty after having had, on average, a 50 percent disability for twenty years, the loss is twenty quality-adjusted years. By this measure, harm from alcohol use amounts to about 10 percent of total disability-adjusted life years lost in industrialized countries.
3It might be argued that the analysis above is insufficient, and I would tend to agree. The measure of disability described is based on the harm caused to the individual using the drug. Clearly, however, addictive drugs also cause extensive harm to others, through crime, accidents, lost productivity, broken families, and other social costs. The former adviser to the British government on matters of addiction, David Nutt of London’s Imperial College, concluded that in aggregate, the harm to self and others inflicted by alcohol exceeds that caused by heroin or cocaine.
4 Although by no means undisputed, this analysis captures something important.
Finally, one might argue that the harm measures from these different sources, while telling us something about alcohol, do not necessarily say much about alcohol addiction. After all, alcohol consumption is widespread among people who are not addicted. But while it is indisputable that only a minority of people who consume alcohol are addicted, and that people can be harmed by alcohol without being addicted, it is also a fact that alcohol consumption in the population is markedly skewed: about 10 percent of the population consumes more than half of all alcohol consumed.
5 Thus an overwhelming proportion of alcohol-related disability is due to what I will call alcohol addiction and hereafter equate with “alcoholism.” This condition affects more than 10 percent of the population at some point in the United States and other industrialized countries.
6 Alcohol addiction is a prototype for a group of conditions characterized by continued use despite adverse consequences. While there are certainly important differences, the lessons learned about alcoholism are therefore helpful for understanding addiction in general. So before moving on, I will spend some time describing what addiction is and is not, with much of the focus on alcohol addiction.