BOTTOM UP
By William Loving, MD, ABAM
It is said "that alcoholics and addicts don't get help until they hit bottom." Families of these patients feel very helpless and suffer a great deal while they watch their loved one sink to this bottom. It's not so agonizing for a "high bottom" alcoholic or addict because something as small as a cross word from a spouse will drive them to seek help or treatment. "Low bottom" patients however may lose virtually everything in their life and end up literally eating out of dumpsters before they seek help. Doctor's have a valuable opportunity to help by bringing the bottom up to their patients so that they will get help before they have lost everything.
Did you know that alcohol and drug problems are involved in:
• 60%+ child abuse
• 60%+ fatal car accidents
• 50% of drownings
• >50% of accidents & family violence, medical problems & ER visits
• 33% of fatally injured bicyclists have elevated BAL
The problem is so big that we cannot see it and then under react to it. The use of alcohol and drugs is quite engraining in our culture and goes along with a natural human desire to have a shortcut to happiness; have control over our feelings; and have a method to shut out unpleasant and difficult parts of reality. The use of chemicals (especially alcohol) has been with man for centuries and probably started the first time a caveman tasted the sweet smelling liquid left behind from a bunch of fermented grapes he had left on the ground. Alcohol and drugs are here to stay, as are the problems that directly affect almost 20% of our population. These people get out of control with one of the chemicals that make them "high" or change the way they feel. Tolerance and dependence sneak up on them, compulsive use continues despite harmful consequences, and attempts to quit become futile. No one uses these substances to get DWIs, make a fool of themselves or cause problems at home or on the job. This is a self-induced central nervous system disorder but overtime the "self induced" part becomes less and less volitional. The end organ for drugs that make a person "high" is the brain and so judgment and insight are significantly affected and the patients become unable to identify their problem even though it may be obvious to everyone around them.
The most effective way to treat the alcoholic or addict is to view the problem as a chronic disease, not as a willpower or moral problem. These patients become truly out of control with their drug of choice to the point that willpower cannot overcome the problem. Research shows that the etiology is multi-factorial but genetic and biological factors are a significant part of the problem. Strong evidence shows that 18% to 20% of our population directly affected has a physiologically different reaction to alcohol and addictive drugs than the average person. They are more strongly affected by the drugs (get "higher") and are more likely to become dependent. These people have a type of "allergy" and the best treatment is total abstinence.
Chemically dependent people need treatment similar to treatment for any chronic or relapsing disease. As in any chronic disease the patient has difficulty accepting the diagnosis and tries to deny and rationalize away the problem. Education is fundamental to the treatment because there is no cure and the patient must be taught to manage the illness just as diabetics and asthmatics are taught to manage their illnesses. Fortunately Alcoholics Anonymous and Narcotics Anonymous (AA and NA) are active, effective, and free groups that provide not only support but also a step wise plan of recovery. The only reason these 12 Step programs have survived since inception at around 1937 is because they are helpful and work. No one profits financially from AA; there are no marketing directors or missionaries; and yet these programs have spread all over the world with Austin alone having more than 50 meeting sites. The 12 Step program is a valuable tool for the patient to use to recover from this devastating illness. Treatment programs help patients learn to use this valuable tool properly while understanding important fundamentals and ignoring the sometimes annoying insignificant sides of AA and NA.
In the early stages of recovery the patients feel and look mentally disturbed to some degree and about 20% of chemically dependent patients have true psychiatric problems (depression or anxiety disorders primarily). Some patients will need a psychiatric evaluation and some will need medical care. Secondary medical problems such as pancreatitis, liver disease, HIV and many other physical problems are common and need to be addressed. Doctors in all specialties have some patients with drug and alcohol problems causing or complicating the disease for which the patient is coming to the doctor's office. Most doctors have little education or interest in the disease of alcoholism and chemical dependency.
What can the doctor do if a chemical dependency problem is suspected? The doctor should discuss these concerns with the patient in a direct and non-judgmental way. For example, an internist knows his patient drinks and then finds on lab work that the MCV and GGT are elevated plus the physical exam shows slight liver enlargement and elevated blood pressure. This patient has an alcohol problem. Rather than minimize the mildly elevated GGT and physical signs the doctor should take the opportunity to talk to the patient about these abnormalities in the most negative of terms. It even helps to show the patient the lab values and to really emphasize the abnormalities and the dangers. This is the time when the doctor needs to help the patient be appropriately fearful of the true dangers to come such as cirrhosis, if they do not stop drinking. This is what I mean by "bringing the bottom up to the patient." The doctor has a golden opportunity to help the patient seek treatment or help before sinking to a "low bottom." We should use this opportunity and our power in the patient's best interest.
What follows is a "cheat sheet for doctors" to give some useful clinical information and tips to help with diagnosis. Also included is a patient handout sheet that can be copied and given to the patient you suspect has a drug or alcohol problem. This handout also contains local referral sources and ways of finding out where AA and NA meet.
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