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.

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.

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.

What The Doctor Means: Cirrhosis and Ascites

As we already know, the liver has a LOT of functions, and these functions are vital to our survival. One of the largest jobs of a healthy liver is to produce enzymes required to metabolize particles in our blood stream. The purpose of this is to either break down molecules to forms that can be eliminated from the body (such is the case with alcohol and many other drugs/medications), or to change their original form to something that can be utilized by the body (such is the case with proteins like albumin and clotting factors). The liver also has many other functions, however, the components of breaking down and building molecules are the two most important when it discussing cirrhosis.

Cirrhosis is what occurs after repeated injury to the liver which destroys the normal, functional liver cells and replaces it with non-functional fibrosis, nodules and scar tissue. There are many causes of ‘repeated injury to the liver,’ which include alcohol intoxication, hepatitis viruses, autoimmune diseases and many others. Alcohol is the second leading cause of cirrhosis in the United States (the #1 cause is Hepatitis C).

As the liver loses its functional capacity, physical symptoms soon emerge. Some of the more notable symptoms are described below.

• Jaundice - yellowing of the skin due to inability of liver to eliminate bilirubin from the blood stream
• Itching - due to inability of liver to eliminate bile acids from the blood (there are other causes as well)
• Bruising – due to inability of the liver to produce clotting factors
• Spider angioma – small bruises on the body, due to elevated levels of estrogen that the liver is unable to break down
• Confusion – due to inability of liver to break down and eliminate ammonia products from the blood
• Asterixis – flapping of the hands when outstretched, also due to excess ammonia products
• Varices – this is the biggest concern for doctors because it can lead to large amounts of blood loss in a short period of time. In cirrhosis, the liver becomes so scarred that even blood has a hard time passing through it, thus causing an increase of pressure in the vessels that travel to the liver. These vessels that are now carrying an increased pressure find a way to release it by either of two means: taking a different path in order to get around the liver, or by bursting open. Hence the concern.

The most important symptom that we will be talking about today is ascites. It is the progressive buildup of fluid in the abdominal cavity that may not be noticeable at first, but eventually leads to an accumulation so great that the abdomen becomes disproportionately larger than the rest of the body.

The cause of ascites can be difficult for some people to explain because it can be tricky and there is a bit of physics involved. However, the physics is simple if explained properly and the small fine details are easy to understand.

The fluid that enters the abdominal cavity gets there via two separate means that are both induced by cirrhosis.

1. The cirrhotic liver loses the ability to produce proteins that are released into the blood stream and travel within the blood vessels of the body. These proteins in the blood cause a force on any fluid outside of the blood vessel to enter the vessel. Basically, the proteins act to pull fluid surrounding a blood vessel in to it. When the liver doesn’t produce these proteins, then you lose that pulling force as well.
2. As we saw with varices, the liver becomes so scarred and fibrotic that the blood that normally passes through the liver freely can no longer do so. Thus, the blood vessels that travel to the liver become congested with blood that has nowhere to go. The increasing amount of blood within the vessels causes an increased pressure on its walls. Since the blood vessels have microscopic passages in the walls, the increased pressure causes the blood to leak out at a higher rate than normal

The fluid that leaks out of the blood vessels due to the elevation in pressure is not able to be reabsorbed because the liver is not producing the proteins that cause the pulling force on the fluid to reenter the blood vessels. This fluid accumulates in the abdominal cavity and becomes the physical sign/symptom of ascites.

This really only demonstrates a small fraction of how important the liver is to us. As I’ve seen with so many people before, many will disregard this subject because they don’t think it pertains to them. These are often the people at the greatest health risk. I have yet to learn how to get their attention.

What The Doctor Means: Liver Enzymes

There are many different ‘liver enzymes’ that a doctor looks at when evaluating a liver function panel (AKA liver function tests). In fact, the liver function panel is not limited to enzymes, it also measures the levels of total protein, albumin, bilirubin, and other molecules that are all produced by the liver and dispersed throughout the body by the blood.

When examining the results of the liver function tests, the total protein and albumin levels will not be altered until there is severe damage to the liver. Severe damage means beyond the level of fatty liver disease and progression to liver cirrhosis. At the point of cirrhosis, the liver is so damaged by fibrosis and scar tissue that the ability of the liver to function as an organ is seriously compromised. Thus, the liver will not be able to produce the proteins/albumin, thus this will be demonstrated on the laboratory test as a decreased blood level of them. The decrease in the amount of proteins/albumin being produced is the reason why cirrhotic patients get ascites (swelling of the abdomen), but that will have to be explained at a different time.

More importantly, what are the ‘liver enzymes’ that your doctor looks at and what do they mean. Well, normally your liver enzymes should remain in the cells of the liver and should only enter the blood stream in tiny amounts. However, when the liver becomes inflamed and damaged by chronic alcohol exposure, then the cells of the liver (hepatocytes) will break down and spill the enzymes into the blood stream. Thus, an elevation of ‘liver enzymes’ is an easy way to determine if your liver has had any damage/inflammation recently.

There are viruses (Hepatitis A, Hepatitis B, and Hepatitis C) that can also cause inflammation in the liver and increase your blood levels of liver enzymes, but there is a simple way to differentiate viral inflammation of the liver versus alcoholic inflammation of the liver that is explained in the following paragraphs.

There are two main enzymes that your doctor will look at in your liver function panel (the other enzymes are not as important unless you have gallstones or other forms of biliary pathology). These enzymes are named Alanine transaminase (ALT) and Aspartate transaminase (AST). In the chronic alcoholic patient, these enzymes will be elevated in a certain pattern that is often easy to discern from other causes of liver inflammation (i.e. viral hepatitis). When the doctor compares the blood level of AST to ALT, the AST will often be elevated by a factor of 2 compared to ALT. For example, in a chronic alcohol user the AST level may be about 120 IU/L, and the doctor would expect the ALT level to be about 60 IU/L.

In viral hepatitis (Hepatitis C), the AST to ALT ratio will be closer to a 1 to 1 ratio and the blood levels are often much higher as compared to in alcohol (usually AST and ALT will be greater than 300 IU/L in patients with viral hepatitis).

I hope this helps some of you who were interested in learning a little bit more about the visit to your doctor. Feel free to ask any questions or ask me to explain something that I didn’t go over too clearly.

Update on Horatio – Late December 2011

Horatio’s work called my father when he did not show up to work a couple of weeks ago. This was then followed a week later by another call from his manager regarding the same subject, except this time he had missed both Monday and Tuesday (I’m reminded of the scene in Office Space in which the consultants inquire about him missing days of work, and he responds, “well I wouldn’t say I’ve been missing it, Bob”).

After receiving the call, my father went over to Horatio’s house and found him completely drunk with an empty 1.75 liter of Smirnoff Vodka in his kitchen. My father asked Horatio to come with him back to his house where it is an alcohol free home. This would allow him to sober up and resume working (I disagree with my father forcing Horatio to come back to his house because this is a form of enabling as well as the fact that it must be my brother’s own motivation to stay in an alcohol free home). From what I heard, there was a lot of resistance to get him to leave his house, but he finally came with my father.

These two occurrences are very disappointing and demonstrate a new pattern of Horatio’s drinking cycle. It appears that he is able to maintain his sobriety during the weekdays in which he must show up at work (sober or not), however, when it comes to the weekend, he is unable to control the temptation to get obliviated with a large bottle of vodka.

A simple solution for him to avoid these severe alcohol binges would be to temporarily move to my Father’s house over the weekend when he is most vulnerable to his weaknesses. Unfortunately, this is not something that he will be too agreeable with, but I hope that he will at least listen and contemplate the idea.

For some reason, I am looking forward to getting home and having a discussion with Horatio. I shall update you after I sit down with him and discuss the current situation. Your ideas and suggestions are much appreciated, feel free to leave a comment or send an email.

Update on Horatio – Early December 2011

It is coming up on 2 months since I last wrote about my alcoholic brother, Horatio. He has had some great success at abstinence along with some unfortunate bouts of relapse. Every relapse is just as hard, if not harder than the last on him.

When Horatio and I sat down and talked 2 months ago, together we decided on two large areas. The first being that he will give me 30 consecutive days of abstinence. We discussed that this is a mountain of a task and that I would not expect him to be able to accomplish this without relapsing at least a handful of times. I emphasized that I did not care if he relapsed, only that he was honest with me when he did so that we could start over from day 1 again. He has still not given me 30 consecutive days, but I look forward to when I can congratulate him on a job well done.

The second order that we agreed on was that he would put all areas of his life aside until he was sober for at least 30 days. This meant that he could not look for a job, he could not look for a girlfriend, and he could not work on other areas of his life that were not directly related to remaining sober. If he wanted to exercise or go to AA meetings or relax with family and friends, then that was perfectly acceptable, so long as it was sober activities. Unfortunately, he has not succeeded in this area either. He had been actively looking for a job and was hired 10 days ago.

This concerns me for many reasons. The primary reason is that Horatio does not have good coping skills. This is what leads him to pick up the bottle in the first place. An individual with poor coping skills will have a much greater likelihood of succumbing to relapse. He has already disclosed to me that over the very first weekend after his first 3 days of work that he had a relapse. Fortunately he was able to sober up before Monday morning and still has the job as far as I know. I assume that it is only a matter of time before they find out his dirty habit.

In our most recent discussion I reiterated that I was uncomfortable with him having a job when he still has not given me 30 days of abstinence. Rather than hassling him about this, we discussed ways to help him cope with stress and made sure that he knew I would always pick up the phone if he was thinking about having a drink. I hope that he has the strength to do so.