Category Archives: alcoholism
Veracity
V for veracity in the Blogging from A to Z challenge.
I am thinking about veracity and my father. Veracity is truth, faithfulness, accuracy, correctness.
I was frustrated about how someone was reacting to something and asked my father about it.
My father said, “Most people don’t want reality.”
“What do you mean?” I said.
“Most people work hard to avoid reality. They have a set of ideas and a world view and they get upset if something does not fit in it or if it is questioned.”
I have been thinking about a song that I learned as a kid. It falls into one of the “Dead Girl” songs, as my sister called them. I think of them as teaching songs. I am taking guitar lessons and my teacher says that he won’t sing those songs.
I will. I like the dark songs. And I am very ambivalent about this song:
There was a wee cooper wha lived in Fife,
Nickety, nackety, noo, noo, noo;
And he had married a gentle wife,
Hey, willy, wallacky, ho John Dougle
Alane, quo rushity roo, roo, roo.
She would na bake nor would she brew,
For spilin’ o’ her comely hue.
she would na caird nor would she spin,
For shamin’ o’ her gentle kin.
The cooper has gone to his wool pack,
And he’s laid a sheep’s skin on his wife’s back.
“I’ll no be shamin’ your gentle kin,
But I will skelp my ain sheepskin.”
“O I will bake and I will brew,
And think nae mair o’ my comely hue.”
“O I will wash and I will spin,
And think nae mair o’ my gentle kin.”
A’ ye what hae gotten a gentle wife,
Send ye for the wee cooper o’ Fife.
This is Child Ballad number 277 and has been recorded by Burl Ives and others.
Ambivalence. It’s a song about wife beating, I don’t approve. But it’s also a song about surviving. A cooper builds barrels. The job division was that the wife would bake and brew, card wool and spin. However, this wife is “gentle” as in gentleman, of “good birth” and rejects the work as beneath her. Does she expect to be served? In the stories of happily ever after, we are happy when the poor underdog poor person wins the love and admiration of the other person, but we don’t see what happens when they go home. In Disney movies, the girls are poor and win a prince. Or Aladdin becomes a prince.
Skelp is defined as “hit, beat, slap”. The song doesn’t say whether the cooper does beat the sheepskin tied to his wife’s back or only threatens to do so.
I love word play so I like the “alane, quo rushity roo, roo, roo.” Nonsense words delight me aside from the topic of the song and I like the tune.
I think that our culture has years of men dominating women and expecting women to obey. I dislike that intensely. At the same time, I don’t like it when people won’t contribute and when they avoid work, so I also have some sympathy for the wee cooper. And our culture spends too much time thinking “happily ever after”, trying to find just the right person. We do not enough time actually asking each other what “happily ever after” would look like. And anyhow, it doesn’t exist. For richer, for poorer, in sickness and health: that is the veracity. We all will have challenges and everyone will have illness and hopefully good times too.
I am thinking of the many people lost in the recent earthquake. Lost: killed suddenly. Enjoy each day and be kind to yourself and others. We never know when grief will strike.
Phoenix Rising
P for Phoenix, for the Blogging from A to Z Challenge. This post is for Amanuensis Sobriquet-Reverie. Her poem today “Burn the witch” brings up present and past difficult memories. Here is the poem I wrote about it in 2003.
Phoenix Rising
Set a torch to me
Why don’t you?
It’s not the tearing sound of fabric
A small rip
And now a tear
That I feel
It’s the torch
I’ve been here before
A job where the idealistic came
As moths to the flame
Self-immolation
Because they had ideals
I watched and burned and rose
It’s the torch
The flames that rise
As the witch is burned
Tilts back her head
In ecstasy and knowledge
Eager to learn what she can
From these burning brands
In the burning we learn
In pain we learn
If we can remain open
Ashes fall to the ground
Buckets of water
Wash any remains to grey mud
Gone, punished
Relief for the frightened
An example has been set
No but what stirs at night
Moon or none
What rises from the mud
The ashes
Takes form
Takes flight
Laughing
Set a torch to me
Why don’t you?
And see what is created
a local bookstore
previously published on everything2.com
Adverse Childhood Experiences
I went to a sparsely attended lecture about the Adverse Childhood Experiences Study, or ACE Study, in 2005 and it blew my mind. I think that it has the most far reaching implications of any medical study that I’ve read. It makes me feel hopeful, helpless and angry at God.
The lecture was at the American Academy of Family Practice Scientific Assembly. That year, it was in Washington, DC. There are 94,000 plus Family Practice doctors and residents and students in the US, the conference hall had 10,000 seats and the exhibition hall was massive. At the most recent assembly, there were more than 2600 exhibitors.
I try to attend the lectures numbered one through ten, because they are the chosen as the information that will change our practices, studies that change what we understand about medicine.
The ACE Study talk was among the top ten. Yet when I walked in, the attendees numbered in the hundreds, looking tiny in three joined conference rooms that could seat 10,000. The speaker was nervous, her image projected onto a giant screen behind her. My experience has been that doctors don’t like to ask about child abuse and domestic violence: I thought, they don’t want to go to lectures about it either.
The initial part of the study was done at Kaiser Permanante, from 1995-1997, with physicals of 17,000 adults. The adults were given a confidential survey about childhood maltreatment and family dysfunction. A simpler questionnaire is at http://www.acestudy.org/files/ACE_Score_Calculator.pdf, but it is not the one used in the study. Over 9000 adults completed the survey and were given a score of 0-7, their ACE score. This was a score for childhood psychological, physical or sexual abuse, domestic violence, or living in a household with an adult who was a substance abuser, mentally ill or suicidal, or ever imprisoned.
Half of the adults reported a score over 2 and one fourth over 4. The scores were compared with the risk factors for “the leading causes of death in adult life”. They found a graded relationship between the scores and each of the adult risk factors studied. That is, an increase in addiction: tobacco, alcohol and drugs. An increase in the likelihood of depression and suicide attempt. And an increase in heart disease, cancer, chronic lung disease, fractures and liver disease. The risk of alcoholism, drug addiction and depression was increased four to twelve times for a score of four or more.
The speaker said that the implications were that the brain was much more malleable in childhood than anyone realized. She said that much of the addictive behaviors and poor health behaviors of adults could be self-medication and self-care attempts as a result of the way the brain tried to learn to cope with this childhood damage.
I left the lecture stunned. How do I help heal an adult who is smoking if part of it is related to childhood events? From there I went to a lecture about ADHD, where the speaker said that MRIs and PET scans were showing that children with ADHD had brains that looked different from children without ADHD. I thought that speaker should have come to the other lecture. And I did not much like my ACE score, though it does explain some things.
I feel hopeful because we can’t address a problem until we recognize it.
I feel helpless because I still do not know what to do. The World Health Organization has used the ACE Study in their Preventing Child Maltreatment monograph from 2006. But it is not very cheerful either: “There is thus an increased awareness of the problem of child maltreatment and growing pressure on governments to take preventive action. At the same time, the paucity of evidence for the effectiveness of interventions raises concerns that scarce resources may be wasted through investment in well-intentioned but unsystematic prevention efforts whose effectiveness is unproven and which may never be proven.”
Do I do ACE scores on my patients? With the new Washington State opiate law, we do a survey called the Opiate Risk Tool. It includes parental addiction in scoring the person’s risk of opiate addiction. But not the rest of the ACE test. At this time, I don’t do ACE scores on my adult patients. I don’t like to do tests where I don’t know what to do with the results. “Wow, you have a high score, you will probably die early,” does not seem very helpful. But I remain hopeful that knowledge can lead to change. And it makes me more gentle with my smoking patients, my addicted patients, the depressed, the heart patient who will not exercise.
I am angry at God, because it seems as if the sins of the fathers ARE visited upon the children. It is the most vulnerable suffering children who are most damaged. That does not seem fair. It makes me cry. I would rather go to hell then to the heaven of a God who organized this. I stand with the Bodhisattva, who will not leave until every sufferer is healed.
1. ACE study http://www.cdc.gov/ace/about.htm
2. American Academy of Family Practice http://www.aafp.org/events/assembly.html
3. ACE questionaire http://www.cdc.gov/ace/questionnaires.htm
4. Score correlation with health in adults http://www.ajpmonline.org/article/PIIS0749379798000178/abstract
5. WHO preventing child mistreatment http://whqlibdoc.who.int/publications/2006/9241594365_eng.pdf
6. Washington State Opiate Law http://www.agencymeddirectors.wa.gov/
7. Opiate Risk Tool http://www.partnersagainstpain.com/printouts/Opioid_Risk_Tool.pdf
First published on everything2 November 2011.
If you have to cry, do it on the boyfriend who wants you to be angry instead of sad
I used to have a temper that could be set off really really easily.
I had a boyfriend right out of college that said that I didn’t get angry “right”. He had a PhD and I was a mere done with undergraduate person, so what did I know? I went into counseling for a year.
Finally I said to him, “The counselor and I have tried presenting anger to you in every possible form and none of it is acceptable. So now she says you need to come to counseling too.”
His response: “What I want is for you to never get angry at me again.”
Mine: “You are dreaming.”
And so he broke up with me. Immediately. And said I was an ogre when I was angry.
I went back to counseling and was depressed for a year. Then I cheered up, met a boyfriend and went to medical school. I worked on my temper, remembering the ogre comment. I did not want to be an ogre. My boyfriend became my husband and he really liked my dark side and my silly side.
My sister was the person who could set me off angry the most easily. She and I fought like pitbulls, like honey badgers. Once we were in Colorado with my husband, her first husband and my parents. The two husbands had an imitation pretend fight acting as me and my sister. They were vicious. It was horribly embarassing and also funny, because they nailed us both.
In residency in Portland, I had a breakthrough. My sister was divorced from the first husband by then, and with the no meat, no dairy, really pain in the butt boyfriend. We were having a big party, lots of people, grilling salmon and cooking in a group. My sister walked in.
“Oh.” I said, “You didn’t RSVP.”
She fired up instantly. “What? Why does that matter? Do you want me to leave?”
I did not fire up. I held my breath and then said, “No. But if you are here with No Meat No Milk, I didn’t make any food for him, because I did not know you were coming. There is lots of food. You are both welcome to stay, but he will have to figure out his own food.” Then I held my breath again.
There was a long pause. My sister had her breath drawn in and held. She looked like she was going to explode. But I had answered quietly. She really had nothing to explode at.
“We will stay then,” she said, grudgingly. And there was No Meat No Milk. I was pretty happy when she ditched him. But I was also happy that I had not exploded back at her.
That was when I really got control of my temper. Not that I never lost it again, but I was no longer an ogre. I could hold it with my sister. My husband could set me off, but when I stepped back and started recording what he said and my responses, I could hold it there too.
After we divorced, I had one boyfriend who moved in. I had joked to a friend that my family had a lot of enablers and enablees, but that the latter lived longer. I said if I had to be one or the other, the latter seemed better for longevity.
And that boyfriend showed up immediately. I had just been “strongly encouraged” by my employer local hospital to open my own private practice. That is, I was not seeing patients. I was writing a business plan. I met him in a bar, salsa dancing. He said I was cute and I said, “No, I’m prickly.” I swear, it was that sentence and my dancing that attracted him. I always grin like a fool when I’m dancing. I love it. It lights me up.
Anyhow, I got mad at him exactly twice before he moved in. Boy did he come down on me for getting mad and punished me very thoroughly. By now you are wondering why I let him move in and frankly I was too. But my intuition was running the show and I just let it.
Well, he had kissed me like crazy at the start of the relationship. He stopped kissing me, almost as he moved in. He had insomnia. He’d fixed up one of the two upstairs bedrooms. He started sleeping with me less and less and sleeping in the other room, on cushions.
I would wake, worry. I started moving too. I moved to the guest room. I moved to the couch. Once I was out of the theoretically shared bed, I could go back to sleep. He protested that I shouldn’t move. Why not? I was getting insomnia from worrying about him leaving more and more.
He said we’d need couples counseling eventually. I said, ok, and scheduled it. He said, “I didn’t mean now!” I said, “Well, seemed like we might as well get it out of the way.”
He told the counselor I needed to either cut my sister off or do what she said, but instead, I was present and disobeidient. My sister had metastatic breast cancer and we came from an alcohol addiction family. Can you say complicated relationship?
I explained to the counselor that I thought many patients with cancer end up in a “cancer bubble”. Everyone tries to do what they say because they have cancer. This isolates them and does damage to the relationship. I was trying to stay present and real. That is, I did not obey. I was getting pressure from other people to obey, because my sister would complain about me. Whatever.
The counselor thought I was reasonable. I brought up the sleep issues. The boyfriend cancelled the counseling, saying that he needed a break.
At six months living together, he was saying that he might need to go back to the city to work. Two hours away. And I still was not doing what he wanted re my sister.
Counseling again. Again my behavior to my sister was examined. Same story. I turned to him. “I hear you saying you may need to return to the city for work. I hear you saying you may need to move there. What I don’t hear you saying is darling, we will get through a long distance relationship. Are you breaking up with me and not telling me?”
Long silence.
The counselor said, “You need to answer her.”
He finally said, “I wasn’t going to tell you until after I moved.”
I cried. We left. I kept crying.
He said, “You are angry and you are going to throw me out on the street.”
“No!” I said, “I am sad! You move out when you are ready! We will remain friends!”
So then I cried buckets. I cried on him, buckets. I cried every time I saw him, I cried daily, I cried about him, about my sister, about alcoholism, about the hospital getting rid of me. I cried about everything. I cried on him daily.
For six months. He kept saying “You are angry. You are throwing me out.” But I didn’t. I just cried more.
He moved out on the weekend I returned from seeing my sister in hospice for the last time. Her birthday was March 23. I saw her last on March 22. My birthday was March 28. She died March 29. He moved out on the 26th and 27th. I was not mad, I just cried and cried and cried.
I think that he was looking for an angry girlfriend. He thought he’d found her when I said I was prickly. He would have been the enabler and I would have been the angry dysfunctional enablee. It turns out that I was not really interested in being an enablee. Now I want a healthy relationship.
So that is my recommendation. If you have to cry, do it on the boyfriend who wants you to be angry instead of sad.
In preparation
I wrote this on 9/26/14 in the midst of much frustration and my lungs still hurting three and a half months after I got sick. I am off from taking care of patients, but still have to try to get my business covered and my patients taken care of. I think there is a component of my vocal cords not working because I am told that I am wrong and to shut up so often.
Favorite example is a Seattle Infectious Disease doctor that I called to ask for help with an infection in our town. He said, “You are a rural Family Practice Doctor. Why would I listen to you?”
I said, “I’m a girl too.” and hung up in frustration. That attitude will not win him any referrals from me. On my permanent stupid moron list, along with an amazing number of specialists. They are either respectful or they aren’t.
Currently I am on no alcohol at all, because I have to do a special diet before a 24 hour urine test. Means no caffeine either, ouch, headache.
In preparation
Today I will start drinking
now
even though it’s only 9:40
in the am
I will stretch two beers
through the long hours
as the alcohol
blocks the receptors
and numbs my aching heart
and lungs
and I will stay home alone
today
so that I won’t talk
time
to rest my voice
in preparation
for the next round
of talk
where I am told
in no uncertain terms
to sit down
and to shut up
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 one drink daily for women and two drinks daily for men, no saving it up for the weekend.
“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 one ounce of hard liquor. If it is a high alcohol beer or wine, 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 in the long term.
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, 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, swollen 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.
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