Category Archives: 7 sins and friends

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Alcohol

Let’s talk about alcohol.

I am a family practice physician and I talk to people of all ages about alcohol. The current recommendation is no more than seven drinks a week for women and fourteen drinks a week for men, no saving it up for the weekend. No more than two drinks in one day for women and no more than three for men.

“What?” you say “No way. Come on, that’s ridiculous.”

My patients don’t say “That’s ridiculous.” After all, they are paying me to do a physical exam and a preventative exam. I am supposed to give them advice. But what is the basis for that?

One drink is defined as a regulation 12 oz beer or 6 ounces of wine or two ounces of hard liquor. If it is a high alcohol beer or wine or liquor, the amount is less.

It is NOT the liver doctors that have given us these numbers. It is the cardiologists, the heart doctors. One drink in women or two in men lowers blood pressure and in general, has good effects. Go over that daily and there is a rebound in blood pressure as the alcohol wears off. Alcohol works in the same way as benzodiazepines: it makes people less anxious and more relaxed and lowers inhibitions. Both alcohol and benzodiazepines are addictive for many people. That is, they develop tolerance, it takes more of the substance to have the same effects, more tolerance and then it takes more and more substance to try to feel half way normal.

Cardiologists qualify this recommendation as follows: there is no recommended daily amount of alcohol that is considered heart protective because there are too many alcoholics. The recommended daily amount of alcohol for an alcoholic is none. The recommended daily amount of alcohol for the general population is none.

Alcohol withdrawal can be very very dangerous medically. I think that the three most difficult things to quit are heroin (and all opiates), methamphetamines and cigarettes, but alcohol is more dangerous. In heroin withdrawal all of the pain receptors fire at once, so it is torture, but people don’t die. With serious alcohol withdrawal, the blood pressure skyrockets and the person can have seizures, a stroke, a heart attack, delerium tremens and can die. In the hospital, benzodiazepines are used to slow the withdrawal, replacing alcohol in a controlled manner.

Alcohol does more than affect the blood pressure. Over time, alcohol can damage the heart and lead to congestive heart failure.

Of course, you know that it can damage the liver and lead to cirrhosis. Cirrhosis is sneaky: as long as there are a few functioning liver cells, the lab work can look pretty normal. The liver makes proteins for the blood and makes proteins that allow our blood to clot. Once there aren’t enough healthy cells to make those proteins, alcoholics will bleed quite spectacularly. If the amount of the protein albumin in their blood is low, fluid leaks from the blood into the tissues: so whatever part is “dependent”, that is, lowest, will be swollen. Alcoholics can have legs with swelling where I can push with my finger and there is a two or three cm dimple. Alcohol also can lead to gastritis and ulcers. If someone can’t clot and they are vomiting blood from an ulcer, the doctor gets a tummyache too, from worrying. Ow. The liver is also supposed to filter all of the blood in the body. As the liver gets blocked with dead liver cells, the blood starts to bypass it. The bypass is through blood vessels in the stomach. Remember that person vomiting blood? The swollen vessels in the stomach are called varicies and we don’t like them to bleed. They are big and can bleed really really fast. The person can die. I don’t like transfusing and really don’t like transfusing 12 units of blood. In end stage alcoholism, the liver no longer lowers the blood level of ammonia. Ammonia crosses the blood brain barrier and poisons the brain. We haven’t even discussed the lack of vitamin B12 and thiamine which can cause unraveling of the myelin sheaths on the long fibers in the spinal cord: this means that the person gets permanent asterixis and “walks like a drunk” even when they are sober. I’m sure I haven’t remembered all of the consequences of alcohol, but that will do for now, right?

How much alcohol daily causes the above charming picture? We Don’t Know. Really. And it is not okay to do randomized double blinded clinical trials to find out. Same with pregnant women: we don’t know if there is a safe amount of alcohol during pregnancy and we bloody well can’t test it. It is safer not to drink while you are pregnant.

In clinic, I ask how much people drink. If they say 1-2 drinks daily, I ask what the drink is. Sometimes they look confused. I explain that I have one patient who has two drinks a day: however, it is a 12 ounce glass with a little ice and a lot of whiskey. I asked him to estimate how much whiskey and he said, “6-8 ounces.” That is, each glass is 6-8 ounces. His blood pressure is not under control and so far I feel like a failure as a doctor with him; he is NOT reducing the amount. In medical school, the two jokes were: How much alcohol is too much? More than your doctor drinks. And: How much does the patient drink? Double or triple what they tell us.

The popular word in college used to be that you could drink one drink an hour and still be “okay”. “Okay” to drive and it would wear off. Sorry, nope. Breathalyzers are now pretty cheap; buy one if you are drinking more than the 1-2 per day. And the college students that are binge drinking 6-8 or more drinks on Friday and Saturday: it DOES have long term effects and it IS doing damage.

Lastly, sleep and depression. If you are having trouble sleeping, don’t drink. No alcohol at all. Alcohol is a depressant. It helps people to fall asleep. But they do not have “normal sleep architecture” and it works AGAINST them staying asleep. People often wake up as the alcohol wears off. And the blood pressure is having that rebound, remember, and often their heart will race. That is withdrawal. If you are having trouble sleeping or you are depressed, do not take a depressant. It makes it worse.

I saw a nineteen year old in clinic who admitted to “occasional” heroin use. “But I’m not addicted,” she said. I said, “Well, that’s good. But I took care of a bunch of people undergoing heroin withdrawal while I was in residency and it looked like one of the most painful things on the planet. So I would advise you to quit while you are ahead.” I saw her a year later and she said, “When I tried to quit, it WAS hard. I was addicted and didn’t know it. I’m off now and I won’t go back.” So if you tell me, no problem, I can quit alcohol any time, I say more power to you. Show me. And if it’s harder than you think, get help.

 

Originally written in 2009 and updated a little today. The picture is just a little fuzzy…like it might be if I was drinking…..

https://www.drugabuse.gov/about-nida/noras-blog/2015/06/addiction-disease-free-will

https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/what-standard-drink

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the unwashed masses

I don’t have any of THEM as patients. The unwashed masses. All of my patients are smart.

There aren’t any unwashed masses.

I have a gentleman who is overweight, obese, diabetes. He is not stupid. He is not unwashed. He is not exercising or controlling his blood sugar right now because the temperature is below freezing. He has a hole in his trailer floor and no heat. So he huddles under the electric blanket.

I have a gentlewoman, also diabetic. She too is not stupid. She is not unwashed. She lost her husband to cancer and then everything else and then was homeless for a period. She has a small house but she has no heat. She stays in bed to stay warm. Her contractor quit before he put in the furnace and he’s gone bankrupt. She is cold.

I have veterans. They are not stupid. They are not unwashed. One was homeless for a long period and pooled his resources with another to rent a section 8 house. I am so proud of them. They are having trouble living together, each would rather live alone. Only sometimes they would rather not be alone. It is hard.

I have a massage therapist. She started to train as a counselor. To be a counselor, she needs a certain number of supervised hours and was getting this through the county mental health. “I didn’t know.” she says. “It is taking twice as long as I thought because half the time they don’t show up. They don’t show up because they don’t have gas, they don’t have food, they have been evicted, their son is in jail, they are in jail. I had no idea. My massage clientele is so different, they pay. I thought poverty was in third world countries, but it is here, in my county. I didn’t know.”

I know the people who live in the woods. A schizophrenic who comes once a month for his shot. He was losing weight. “Why are you losing weight?” I demand. “I am only eating once a day.” he says. I nag him to go to the community meals. He is shy, he is afraid of people and he is hungry. He is not stupid. He is not unwashed.

I have opiate addicts. Six years ago one expressed concern. He is 6 foot 5 and big. “I am afraid of some of the other people. You shouldn’t be doing this! It’s too scary and dangerous!” My opiate addicts are not stupid. My opiate addicts are not unwashed. Sometimes they relapse. Sometimes they die, in their 50s, 40s, 30s, 20s.

One in six people in the US is below the poverty level. They are not stupid. They are not unwashed.

And when someone talks about the masses, the people, the stupid people, most people are stupid, the sheep….

….I am beyond angry….

….my heart hurts….

Poverty in the US: http://www.census.gov/newsroom/press-releases/2016/cb16-tps153.html.

More: http://www.census.gov/topics/income-poverty/poverty.html.

The examples are taken from 25 years of practice, details changed for hipaa, but I can list dozens at any one time. The photograph is during the sunset after clinic, when I walked down town, the view across the sound.

 

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Pandora’s Box

I read this: Was Pandora framed? today and thought, I know I have a Pandora poem….and here it is, from 2011. And another write up, Why the number line freaks me out, that too. When I think of infinity and Pandora’s Box…. it’s worrisome…

Pandora’s Box

Oh, you’d think
It would be empty by now

But I open the box again
I say what I want

And hear “No.”

I sit in want
Old wants
Buried wants
Pressure rising

I know by now
What is happening
I let it rise in me
I do not fight it
I clean the bathroom
Scrub tile and grout
Wants claw inside me
Burst like striking oil
A geyser from within
Black sticky want
Screaming up through the air
Falling everywhere
Filthy, flooding

It will take a while to clean up
this dark matter,
pollutant to poison
or fuel to sustain?

 

I took the photograph yesterday on North Beach. It looks like a popped child’s toy, pink. But it’s not…. it is all over the beach. A seaweed? Something hatching? Nature is a Pandora’s Box as well…. infinitely creative….

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Under the surface

For the Daily Prompt: mope.

Mope. We think we should not mope. Go down, be down, downer, don’t go there… but sometimes we have to let ourselves feel, and feel deeply, even if it’s not the popular feelings.

I was grumpy four days ago driving with my daughter for a skiing vacation. She gently told me not to grump at her. By the next morning it was clear why I was grumpy: an awful cold had come to visit and I was not going to ski. And I probably got it from her, but maybe not, and it doesn’t matter. I moped a little, but was mostly proud that I rested for two days and did not try to push through it, power through it, feel the burn…. I’ve done that too many times and then gotten really sick. I rested for two days and slept for twelve hours daily and moped a little. And yesterday I did ski for part of a day. Then we drove home, my daughter driving most of it, and I hurt all over by the time we got home….

If every feeling is a gift, a visitor, sent from the Beloved, as Rumi writes… welcome them all. This body is a guesthouse, says Rumi. Welcome moping and treat it gently and with kindness and understanding, as we all long to be treated….

The Guesthouse.

 

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At what age should we talk to our kids about drugs?

I am a rural family physician and my recommendation: before age 9. Before third grade.

WHY? Your eyes are popping out of your head in horror, but my recommendation comes from surveying my patients. For years.

The biggest drug killer is tobacco. However, it takes 30 years to kill people. It is very effective at taking twenty years off someone’s life, destroying their lungs, causing lung cancer, heart disease, mouth cancer, breast cancer, uterine cancer, stomach cancer, emphysema, heart disease….

I ask older smokers what age they started smoking. This is informal. This is not scientific. But most of my male older smokers say that they first tried cigarettes at age 9. I think parents need to be talking to their children about cigarettes by age 9.

And then start talking about alcohol and illegal drugs and the terrible dangers of pills.

“My innocent child would never….” Unfortunately my daughter said that as a senior in high school in our small town, there were 4-5 kids out of the 120+ that were not trying alcohol and marijuana. But there are kids trying far worse substances. We have methamphetamines here, and heroin, and pain pills sold on the street.

The perception that pills are safe is wrong too. Heroin is made from the opium poppy and it’s rather an expensive process, not to mention illegal and has to be imported from dangerous places. But teens take oxycodone and hydrocodone, bought on the street, to get high. And now drug sellers are making FAKE oxycodone and hydrocodone and selling that on the street. It contains fentanyl, which is much much stronger. If the dealer gets the mix wrong, the buyer can overdose and die.

Talk to your children young! NEVER take a pill from a friend, never take someone else’s medicine, never take a pill to party! YOU COULD DIE! And if you have a friend that is not making sense, that you can’t wake up, DON’T LEAVE THEM! Call an ambulance. Your friend may have used something illegal, and may not want you to call an ambulance. But if you think they are too sleepy….. don’t take a chance. People can get so sleepy, so sedated, that they stop breathing.

And parents, you are the ones that have to set a good example. Don’t drink alcohol every night. Don’t use pot every night. Take as few pills as possible. Pills aren’t necessarily safe because they are “supplements” or “natural” — hey, opium and heroin are plant based! Stop using tobacco and if you have a hard time doing it, tell your children you are struggling. It takes an average of eight tries to quit smoking. Get help.

Lastly, we talk about childhood innocence, but we let kids babysit at age 11. That is the Red Cross youngest age. My daughter took a babysitting course at age 11 and babysat. If we think they are responsible enough to do CPR, call 911 and do the heimlich maneuver, shouldn’t we also be talking to them about addictive substances by that age?

Talk to your children about addiction young… so that they can avoid it.

I am submitting this to the Daily Post Prompt: calm. I am not calm about this topic, but the photograph is calm…. and if we can help more children and families…..

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alphabody

arms around
breasts beckon
curious cunt
deviant dong

erogenous ear
fleeting fungk
great gams
hind hunting hugs

in inner inside
jumping jack
keen kind kisses
langerous lick

mmmm man men
numinous nuzzling
open orafice
pounce pound

query queer quickie
raunchy raking
strong slipsliding
tupped trumpeting

undulating underneath
vivid vinelike vending
watch wearing white
xenophobic

yes yes yes yes
zoo zoooooom

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out of minutes

I just read your email

my phone was out of minutes

the internet was down

I was really busy working

I didn’t hear the phone

I forgot I turned it down

 

and you are out of minutes

 

The photograph is from 2007. The dunes collapse, sometimes whole sections with trees. It’s not a safe space to play.
I am choosing this for the Daily Prompt: flames.

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On death and feelings

When my mother was dying of cancer, she did not want us to cry.

So we didn’t. We had her at home in hospice for nearly six weeks and we did not cry. Almost.

My sister called me. “I started crying today, at the kitchen table.” My mother was in another room in the hospital bed. “Everyone left. No one stayed with me. Everyone left.”

I didn’t cry but when people called to say how were things, I couldn’t speak. I sat there with the phone, silent. Because what I wanted to say was my truth and I knew very well that that was not what they were calling to hear. So I did not speak.

After my mother died, time passed. I felt…. many things, but the strongest one was “I wish my mother had let me cry.” We did what she wanted. But I wanted to cry.

My sister got cancer and fought it ferociously. She refused hospice until the last week. I flew down three times in the last two months.

Six days before she died, her friend and I were helping her. “I’m sad!” said my sister.

“Don’t be sad.” said the friend.

“It’s ok to be sad.” I said. “What are you sad about?”

My sister started crying: “I won’t be at my daughter’s high school graduation! I won’t see her get ready for prom! I don’t want to leave her!”

“You won’t leave her.” I said. “You will be there. Not in this form.” I meant it absolutely.

“I want to stay!” she said.

“I know.” I said. “I am so sorry.”

With my sister, I did not do what she wanted. I thought of my mother and that I wished she had let me cry. With my sister, I tried to listen to what she wanted and listen to what I wanted. I tried to be honest with her. She even got mad!

But… I watched her go in the cancer bubble. Where fewer and fewer people were being honest. They were afraid. They did what she wanted. They wanted her to be happy. And she tried so hard….

When I had arrived for the last visit with my sister, she was sitting with my cousin. I hugged her. She was not speaking much. I asked if she would like me to sing something and she nodded. I started singing “I gave my love a cherry”, a sweet lullaby. My sister shook her head, angry and fierce. I studied her. “How about Samuel Hall?” I said. My sister smiled and nodded. I started singing “My name is Samuel Hall.” It is about a man who is going to the gallows for killing someone and he is entirely unrepentant and angry. My cousin looked at me, startled. “I haven’t thought of that song in years,” he said. We both sang it to my sister. “To the gallows I must go, with my friends all down below, damn your eyes, damn your eyes.” That was the right song, angry, resisting, raging. “Hope to see you all in hell, hope to hell you sizzle well, damn your eyes, damn your eyes.”

I flew back to work three days before my sister died. I am told that she was scared when she died. “I said, don’t be scared.” said a friend.

Why not? I thought. Why can’t the dying be scared, be anxious, be angry? Why are we afraid to let them? I would have said, Why are you scared? And I would have said, I am scared too. And sad. And angry.

I told my counselor once that my husband was on the couch, angry, and I had to leave the room.

“Why?” she said.

“I am afraid.” I said.

“Why?” she said.

“I am afraid he’s angry at me.” I said.

“So what?” she said.

I thought, so what? “I want to fix him. I want him to not be angry.” Even if it isn’t at me.

“Why can’t you stay in the room?” she said.

I practiced. I stayed in the room. He was angry, grumpy, acting out. It’s not my anger. I don’t have to fix it. It may be just or unjust. Does it really matter? It is his anger not mine. I can stay present.

A friend said that his friend was dying leaving small children. “He was so angry that almost all his friends stopped visiting.”

A man and his sister are not speaking four years after their father died because they disagreed so strongly about how his lung cancer should be treated.

An elderly woman in the hospital agrees to go home for care with her son when he is present and with her daughter when she is present. When neither is present she will not make a decision.

A woman says to me that she is angry that hospice didn’t tell her which drug to give at the end to keep her friend from being anxious.

I hope that we learn to stay present for the dying and for the living. For all of the “negative” emotions. I see most of my hospice patients want LESS medicine rather than more. As their kidneys fail, the medicines last longer. They do not want to be asleep. They may cry. They may be angry. They may be unreasonable. Why should they be reasonable or nice or peaceful?

We want most to be loved entirely. Even when we are sad or whiney or angry or anxious. Who wants to be left alone when they are afraid? I hope we all learn to stay present.

And when we were alone, in that last three days, my sister said “I’m bad!” I said, “You are not bad. You’ve done some really bad things.” She said, “I’m sorry.” I said, “I love you anyway.” And she lit up like a buddhist monk, like an angel. And we both cried and I am so glad I was there.