Update on Horatio – March – Hope

There was an incident at home that prompts attention before hope appears. Horatio has been staying at my father’s house more days than not. This is good for two reasons; he isn’t allowed to drink there and it provides a way to watch his binges. When he disappears to his house for two days and comes back bleary eyed, we know what he was doing. Horatio isn’t as devious as he thinks. Or is it that he has determined we’re oblivious?

A couple of weeks ago he came strolling back to my father’s house after one of his two day vacations. Still drunk from the binge, he attempted to make breakfast for my father. Clearly he was intoxicated, but my father did not reprimand this behavior. Instead, he quietly ate the half burnt/half runny “scrambled eggs.”

I couldn’t understand his rationale for disregarding Horatio’s state of inebriation. After discussing it with him, the only explanation is that he was at a loss for words at that moment and didn’t know how to react. In hindsight, he knew he shouldn’t have tolerated what happened.

The next day, when Horatio sobered up, my father didn’t hold back in giving him a verbal lashing. I arrived home a few days later, at which time Horatio and I discussed the event. He didn’t deny any of his behavior because he had already been confronted about it. This allowed for an open and honest talk about alcohol.

At the end of the conversation, I made sure that the ground rules were reiterated. There would be absolutely no alcohol in my father’s house. This includes any alcohol in his blood. He will not be tolerated and will not be allowed to stay if his BAC is greater than 0.00. If this means he must sleep in his car outside of the house, then so be it.

At the end of the conversation, my siblings began showing up. The evening would be filled with fun loving childish games as our 7 year old nephew tugged on our arm to get us to play soccer and launch rockets high in to the sky.

The weekend continued this way with museums, kite flying and such. As we were all interacting I was noticing something that I hadn’t seen in a while. As I watched Horatio, I could see a little spark of fire in him. The light had been smothered by alcohol for the past decade, but it was flickering and gaining strength in front of my eyes. The more that Horatio let himself go and enjoyed being with people, the less he thought about his addiction.

It brought me hope that Horatio would one day overcome his lustful relationship with alcohol. It’s obvious that he enjoys being sober more than laying on his couch unconscious. There are many more relapses in his future. He is fighting something that is greater than him at this current time. It will be a remarkable day when he is able to harness and kindle that motivating factor that I have seen in so many of you that I follow. The entity that is defeating him will be overcome by his strength, igniting a lifelong abstinence from alcohol.

LSD Helps to Treat Alcoholism

Writing a blog is an entirely new experience for me, and twitter is an even newer experience. I tell myself that I’m young, I should be savvy with these social media forms. However, twitter is something that I just can’t get used to. Once something starts trending, it quickly becomes the only topic on everybody’s mind. And when a patient comes in to the clinic/office to discuss a twitter subject, it can be hard to keep my composure.

A recent journal article published in ‘Scientific American’ titled, LSD Helps to Treat Alcoholism, has been trending in every subject related to alcoholism. It has come to the point that I feel it necessary to add my two cents to this ridiculous subject of LSD as a means to cure alcoholism.

I created this animation to add my two cents

While the journal article is new, published on March 9th 2012, the data is from the 1960′s. The article uses this data in a retrospective meta-analysis to determine if there are any new conclusions that can be drawn when the data is looked at differently. Usually a researcher will have a new hypothesis to test and he/she will use the old data to answer the question. This is a common research procedure and it’s absolutely legitimate.

In this particular article, the authors combined multiple studies that were done in the 1960′s to increase the total number of people in their new study. The purpose of having more people is so that there will be a greater likelihood that the conclusions/results will be similar to the general population. This essentially increases the statistical power and strength of their new study.

The new study determined that people receiving LSD reported lower levels of alcohol misuse. As per the article, “59% of people receiving LSD reported lower levels of alcohol misuse, compared to 38% of people who received a placebo.” When taken at face value, it appears that this is a clear indication that LSD decreases peoples use of alcohol.

What people on twitter don’t consider or realize are the confounding variables. Maybe the subjects reported lower levels of alcohol misuse because they were so wasted from the LSD that they couldn’t even find the liquor store. Or maybe they were so busy trying to obtain more LSD because it was so addictive that they forgot about their alcohol craving for the time being. These are oversimplified alternatives, but such factors must be considered before people come to the conclusion that LSD should be used to treat alcoholism.

The best thing about this blog is that everybody that I have met here has a much more profound understanding of addiction. You know that there is no such thing as a silver bullet to rid the craving. The only way to overcome it is through strength from within. The means that you find that strength is unique to each of you. And that is why I truly enjoy every person here.

Note: Mrs Demeanor did a good job of bringing my attention to a mistake in this post. I make the association of LSD being addictive, when in fact the research shows that LSD is not addictive.

Heed The Fourth Year Spoils

Looking back on the first three years of medical school, it’s hard to imagine living through the endless days of studying again. Weekends were spent cooped up in the library. There were countless holidays that I wasn’t able to enjoy with my family. Instead, they were spent memorizing indecent aspects of the human anatomy and performing DREs on strangers. There are better ways to get to know a person in the hospital, but sometimes the DRE is the only social tool necessary.

As one peruses the social media outlets about doctors and the medical field in general, the consensus is that there is a feeling of disdain harbored against us. It’s hard to determine why people have such negative views on medicine, maybe it’s because they encountered one of the bad apples, they were injured by a physician, or maybe they weren’t properly educated about their disease and its outcomes. In any case, my class will be entering a field that has very mixed feelings toward us, despite the fact that they know nothing about us.

Just as you may think that you don’t know me, there has been a feeling that I don’t particularly know myself. Have I been changed by the hardships of these past four years? Do I look upon people who do not choose to pursue an MD degree as lesser than I? To answer this question, I do not. However, I do have a different respect for my colleagues; much like a Marine sees the soldier standing next to him differently after surviving the grit and grime of warfare.

There is no doubt that we have changed in these past four years. Fortunately, if there is one time in our career of medicine that we will able to find ourselves again, it is during the fourth year of medical school. Before we walk through the very last threshold to becoming a doctor, I strongly suggest you try to relearn who you once were. Residency will not allot you the time for self-reflection or self-exploration.

There were many things that I had to set aside for medical school. It hasn’t been until now that I am finally able to pick those things back up and appreciate them in a different light. I have always wanted more time to read and write, and now I have it. I have always wanted to push myself physically, thus I completed the 2011 Tri-State Tough Mudder. There is nothing better than feeling the warm morning sunshine on a Spring day, I plan to enjoy many of those soon.

I could calculate the immense amount of time required attaining the status of ‘fourth year medical student,’ but alas I’m in too much bliss from the spoils of being able to go to the gym or read a non-medical book to tax my brain in such a way. Unfortunately, these small elations will not be as easy to come by when July arrives and we become interns.

This is why I was so distraught that I lost my appetite when a classmate recently told me about her day. Apparently, it was a slow morning and my classmate wasn’t learning much more than how long it takes for Benjamin Moore White Satin paint to dry on the wall of the on-call room. Thus, around 1:00pm she concluded that it takes 5 hours and 27 minutes, which was the same time that her resident realized how bored my friend was. The resident asked her if she wanted to take off since there wasn’t anything else to learn. Unfathomable to me, my friend denied the opportunity to be relinquished from utter boredom, choosing instead to stay a few more hours. To this day, I still can’t comprehend her decision.

Therefore, my goal is to spread the message to all upcoming interns to take this chance to relearn who you are and what you enjoy so that you will be equipped to handle the long journey ahead. This will make you a better person so that you don’t burn out or begin despising your patients. In turn, this will help to assuage some of the negativity that surrounds our profession. And believe me, the resident you’re working with right now will encourage you to do the same. They remember exactly how they felt the day the match list came out.

Two Types of Alcohol Dependence

I have never met two active alcoholics that are the same. Although their lies and deceit can be predictable, there will always be a spectrum of personality characteristics that will differentiate each person. You might argue that aggression would be a common trait seen in alcoholics, but I would have to disagree. Horatio, for example, is rarely found exhibiting aggressive behavior when he is loaded up (this may be because all of his aggression is directed inward).

The Diagnostic and Statistical Manual (DSM IV) has historically divided alcohol abuse patterns in to either alcohol abuse or alcohol dependence. In short, the individual that succumbs to alcohol abuse has a life that is not as impaired as someone with alcohol dependence. The latter individual will be so affected by the substance being in their system that they will demonstrate physiological dependence on the drug i.e. tolerance and withdrawal.

Many in the mental health community further argue that the alcohol dependent patient can be qualified as either of two types. I personally disagree with having two nice and neat categories for the same reason that I don’t feel that people with alcohol addiction can be minimized to having only a narrow spectrum of personality traits. However, it is good to discuss this topic since it brings up common arguments.

The main areas of focus that differentiate the two groups include:
Genetic predisposition
Age of onset
Pattern of onset
Gender
Severity
Personality traits
Risk of abusing multiple drugs.

Type 1
There is less evidence of a genetic predisposition in this patient. Their drinking pattern is usually attributed to events in their life such as losing a job, financial hardship, or stressors at home. The use of alcohol in this group is to assuage the anxiety produced in their life, however, this behavior acts as a positive reinforcement which quickly leads to dependence. The ratio of males to females in type 1 is equivalent, and the severity of alcohol dependence is less as compared to type 2. The personality characteristics commonly seen in type 1 include a tendency to feel anxious, shy, pessimistic, sentimental, emotionally dependent, rigid, reflective, and slow to anger.

Type 2
There is more evidence of a genetic predisposition in this group. The onset of heavy drinking is often before the age of 25. Their pattern of drinking is not necessarily related to stressful events because they commonly drink regardless of the situation. This group is predominately composed of men and often there is a history of fights and arrests. The degree of alcohol dependence is severe as well as a greater risk of abusing other drugs. Type 2 is associated with people that usually don’t experience guilt, fear, or loss of control over their drinking. They tend to be impulsive, aggressive risk takers, quick-tempered, optimistic and excitable.

After reading this, it may be hard not to think that the point of this post was to fit each person neatly in to a single category. That’s actually quite the opposite of my thoughts. It’s more important to realize that there are some similarities between alcoholics. We may find ourselves relating to one type, or the other, or to both. You are a unique individual, and it is better to understand yourself outside of criteria or characteristics.

My First AA Meeting

Through the motivation of helpful and caring people like Jen, Heidi, and Eden I attended my first AA meeting on Sunday. It surpassed many of my expectations; however it ruined others and left me slightly dumbfounded.

My imagination, with the help of television and movies, painted a picture in my mind of what an AA meeting would be like. It portrayed a room filled with people that obviously looked like addicts; unkempt appearances, borderline offensive hygiene, and at least one person emitting a radiance of booze while swaying back and forth in his chair, balancing on the line between falling forward to the ground and staying in the seat.

You should ignore the video if you only know Bob Saget as Danny Tanner from Full House.

My imagination laughed at me as I entered the room. One look around made me realize that I was deceived. The majority of the members were clean, well kempt, and looked healthier than my medical school classmates. Skeptical, I scanned the room again for the person that showed up with a pint of liquor in his/her system. My imagination rationalized that they must have not shown up today, for certainly you can’t have an AA meeting with 100% sobriety. To say the least, I’m still discouraged by its elaborate depiction of this clean and encouraging environment.

After walking through the threshold and soaking it all in, I found a seat near the back where I assumed the newbies were relegated to. Upon finding my spot, I was immediately welcomed by an older gentleman, John, whom was eager to invite me in and listen to my story. I explained everything that you already know about me i.e. intrinsic interest in addiction, Horatio, and an interest in learning from the people that have the greatest depth of knowledge and widest breath of experience in alcoholism, you.

John and I hit it off and he had a great story that ended in him picking up alcohol counseling after retiring from the school system and being happy and sober for the past 27 years. He introduced me to his friends in the meeting who were equally as welcoming as John. As the meeting got underway, I reprimanded my imagination again for feeding me lies.

It was an open discussion that began with the storytelling of one member’s lifelong battle. This was followed by comments from the audience about how they could relate and included a glimpse of their own story which allowed me to capture a little bit of each person in the room. I would be lying if I told you that I did not relate to the thoughts and expressions in the words that I heard.

I found myself intrigued by a discussion on dealing with life events by using alcohol. Many of the members agreed that at one time or another they used alcohol to squelch negative feelings, even if it was as minor as a bill in the mail. This brought my thoughts back to college years. I couldn’t ever comprehend the thought process of the one or two friends that after breaking up with a boyfriend/girlfriend would announce to the world, “I need to get drunk!” Why is it that people want to get drunk when that is the least effective remedy for such an ailment? In fact, alcohol tends to make it worse because the person inevitably makes a bad decision that night. Taking an already emotionally laden person and adding alcohol is like throwing gasoline on a flame. My hope would always be that the night would end in crying over the person rather than the late night vandalism of his/her house.

As the discussion continued, I was struck by another gentleman’s comment on hitting bottom. A rough rendition of his words was, “I thought I hit rock bottom 20 years ago, but I was wrong. Many years later I found out that at the level I thought was rock bottom there was still an elevator that went even deeper to the sub-basement.” This is a subject that I’ve been thinking about tremendously when it comes to Horatio. What will his rock bottom be (or sub-basement)? I know that I can’t force him in to sobriety. The hardest part may be that the only thing I can do is watch and wait for that day. Will it be when he loses his house? Maybe his addiction will take him as far as living on the streets before he’s finally ready to change for good. I have been mentally preparing myself that one day I may have a homeless brother.

As the hour came to an end, I expressed my appreciation to John for taking me under his wing in a place I would have otherwise been lost. Knowing my interest in learning, he informed me about an AA meeting oriented to young addicts (under 25). I look forward to the discussion I will hear there, as well as at my first Al-Anon meeting.

DUI

Reblogged from earlyrecoveryblog:

I remember shoveling mud out of a drainage ditch in an elementary school in Pacifica. It was part of the Sheriff’s Work Program that followed DUI school. I remember not trying very hard. I remember parking near the sheriff station with my temporary license, or my suspended license, remember not being sure which it was, and panicking as I pulled away at the end of the day, waiting for sirens.

Read more… 373 more words

My hardheaded brother (not Horatio) recently appeared in front of the judge to discuss a DUI. This is his third DUI, of which the last two were within a 5 year period. My family and I were expecting the book to be thrown at him which would ensue in a hefty sentence on top of the lengthy restricted license and weighty fines. This is not what happened. His lawyer provided my brother with a ‘Get Out of Jail Free’ card (the card wasn’t actually ‘free’ considering the lawyer fees) which allowed him to skate by the penal system and subsequently not learn from the serious infraction. This post by earlyrecoveryblog does an excellent job of depicting the depth of denial that addiction burrows into the addict’s subconscious mind. Much like the incidents in the author’s life, the slap on the wrist that my brother received was not enough for him to change his ways. I just hope that he doesn't seriously hurt somebody before realizing the ramifications of his actions.

Alcohol Use Disorder

The Diagnostic and Statistical Manual (DSM) is published in order to have a standardized language in the mental health community. Any change to a classification or criterion of a diagnosis is fretted over and fought over for months and years. There is a diagnosis that will be changing which must be discussed.

In May of 2013 the fifth edition of the Diagnostic and Statistical Manual (DSM V) will be dispersed. This publication will essentially eliminate two diagnoses from its predecessor. The classifications of alcohol abuse and alcohol dependence will be replaced by the term, Alcohol Use Disorder.

Alcohol Use Disorder is derived from many of the same basic premises of the two terms it eliminates. The most important of these include: increasing tolerance to alcohol, withdrawal symptoms if alcohol is stopped, larger amount of time spent procuring alcohol, and daily activities are impaired by it. Below is the full diagnostic criteria.

Alcohol Use Disorder
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:
  1) Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
  2) Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  3) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
  4) Tolerance, as defined by either of the following:
     a) A need for markedly increased amounts of the substance to achieve intoxication or desired effect
     b) Markedly diminished effect with continued use of the same amount of the substance
  5) Withdrawal, as manifested by either of the following:
     a) The characteristic withdrawal syndrome for the substance
     b) The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  6) The substance is often taken in larger amounts or over a longer period than was intended
  7) There is a persistent desire or unsuccessful efforts to cut down or control substance use
  8) A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
  9) Important social, occupational, or recreational activities are given up or reduced because of substance use
  10) The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
  11) Craving or a strong desire or urge to use a specific substance.

The degree of severity is determined by the number of criteria that the patient meets:
Moderate if he/she meets 2 to 3 of the criteria.
Severe if he/she meets 4 or more of the criteria.

The diagnosis is further broken down in to whether or not the patient is physiologically dependent on the drug. Physiological dependence is determined to be evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present).

Thus, a diagnosis may look like:
Alcohol Use Disorder, Severe, With physiological dependence
or
Alcohol Use Disorder, Moderate, Without physiological dependence

The most interesting part for most that read my blog is that the DSM V will define the stages of recovery. I will have to elaborate on them in a different post, but I can list the categories here:

Early Full Remission
Early Partial Remission
Sustained Full Remission
Sustained Partial Remission
On Agonist Therapy
In a Controlled Environment

Update on Horatio – February – Pessimism

The buildup of anticipation and optimism crumbled in disappointment when I arrived home. My father laid down the events that occurred while I had been gone.

Horatio didn’t learn from the first two times that he neglected to show up for work, so he felt a third was necessary to drive it home. Consequently, he had been unemployed for the previous three weeks and has not been sighted for even longer. This meant that throughout the past few weeks he had been in an all-out brawl against his liver to destroy as much remaining functional tissue as possible.

I knew what I would find walking through the door to his house. The TV would be playing a movie at a volume that was way too loud for an incoherent audience member, the bathroom would stink like cigarettes, the refrigerator would be empty, save for a ketchup bottle, his pantry would look much the same, and Horatio would be passed out on the couch with a 1.75 liter bottle of vodka on the floor in front of him.

What would be the point in seeing this all too familiar scene? He’d be drunk, therefore there was no point in having a discussion that he wouldn’t recall having.

I went over there regardless of the sad sight that would be encountered. After letting myself in with the spare key, I could see that everything appeared as expected. I walked over to the unconscious body on the couch and gave him a sternal rub to judge his level of intoxication. Horatio’s head rose slightly and his eyelids retracted only enough to see a sliver of his pupils. He will not remember seeing me.

Picking up the half-empty 1.75 liter of vodka, I walked over to the kitchen sink. Turning the bottle upside down allowed some of the caustic vapors to reach my nose. The piercing smell sent my stomach churning in empathy for Horatio.

As the rest of the bottle drained I found a notecard and pen to write him a note. The note was rather long, but can be summarized in a few words. I explained my disappointment in his recent choices; that I know he is stronger than this; and that I love him no matter what. When the bottle finished draining I placed it on the counter with the notecard on top of it and left.

Do I Drink Too Much – BBC Documentary

John Marsden, a very well established Australian writer with a penchant for alcohol, delves in to the depths of alcoholism. Utilizing the saying, it takes one to know one, he creates a knowledgeable documentary. Below, I reiterate some of his thoughts because I find them to be particularly interesting.

I’ve heard many stories, as well as my own, of having a first drink in the teenage years. It’s shocking to see experiments in this film demonstrate that teenagers, as compared to adults, are better able to handle the same dosage of alcohol. Even when performing tasks, the teenagers are less hindered by the intoxication of alcohol.

He also brings up a great question that I often find ruminating in my head. How many people truly consider the damage that alcohol does to their body? I often discuss this with people who have already had the realization that he or she is an alcoholic. I find it refreshing that the majority of individuals that are aware of being an alcoholic, are also cognizant of the negative impact that drinking has on the body. However, I am plagued by the question of how many people don’t contemplate what it’s doing to their body. Many of these people don’t even realize they are an alcoholic and reside in a state of denial. It is these addicts that put me at unease because it may be too late before they realize what they have done through the years of continual inebriation.

There is a vast amount of research going on in the world of addiction. One of the research groups that John visits states, for those people whom ‘get a big kick from alcohol,’ they may be more predisposed to becoming an alcoholic due to a mutation in their genetic make up. It is possible that as much as 12% of white men have this mutation which puts them at risk for alcohol dependence. This doesn’t necessarily answer the, ‘why do I drink?’ but it may help to understand the dysfunction of relapse.

Toward the end of the documentary, John made a statement that pierced through my chest. Throughout the film he is searching for why alcohol is so addictive, and this is one of his thoughts along his journey. ‘An alcoholic isn’t just created overnight. It seems to take years of subtle, incremental changes. And that was really what happened in the case of my father. Changes occurred gradually over time, his drinking became more and more intensive, sustained and problematic. Nobody sets out to be an alcoholic and he certainly didn’t, it just happened.’

I’m sorry, but it appears that BBC has taken down the last 2 clips from this documentary. I am trying to find a full length version that can be posted. Also, if you know how, the documentary can be found on torrents.

Update on Horatio – January – Optimism

I recently sat down with Horatio after learning that his manager had to call my father due to an unplanned and unexpected absence from work. My father felt obligated to bring Horatio back to his home, which is an alcohol free house. He was then able to sober up and resume work without too many repercussions.

Since Horatio started his most recent job, he has developed a new cycle of drinking to fit this lifestyle. He has been able (as much as possible) to remain sober during the week in order to meet his work obligations. However, when Friday arrives he is resolved of these responsibilities, which allows him to drown himself in alcohol until a state of incoherence is achieved and maintained. This goes on until Monday morning when he is supposed to be present at work. It appears that when he has the golden opportunity to spend Friday evening until Sunday evening absolutely smashed, he is unable to fight this temptation despite his desire to remain abstinent from alcohol.

This of course was what he was doing during most of the weekends that he didn’t have to show up at my father’s house for family events. This led to his second extended weekend of drinking in which his work was kind enough to call my father again to see if Horatio was okay.

Coming home for the holidays, I am eager to talk to Horatio. There is a sense of disappointment due to the increase in frequency of his binges as of late; however, there is also a feeling of optimism. If Horatio maintains his job for more than 6 weeks, then he will be able to take advantage of the health insurance benefits.

With insurance he will be able to resume sessions with his psychologist. Therapy has had a positive impact on him in the past. With a psychologist, he is able to bring up emotions and issues that he is unable to divulge in a normal sober setting. Acting as his therapist is not a role that I am able to fill because of the position that I already play in his life. Horatio needs to be able to talk to someone that he feels is non-judgmental and of neutral feelings regarding his history.

Health insurance will also allow him to restart his medication regime of disulfiram (Anabuse) and naltrexone. These medications are by no means silver bullets in ridding the body/mind of the intense desire to self medicate with alcohol, but they do help to cut the edge.

I hope that the upcoming discussion with him is as positive as I am optimistic about it.