"Do you think maybe Uncle Joe has a drinking problem?"

November 24, 2009

As we reach the pinnacle of the drinking season (Thanksgiving through New Years) many people not in the business are thinking about addiction. It may be a concerned reflection on our own behavior over the past* coming month or so. It may arise from unusual levels of contact with our distant relations or family friends. Even though drinking, even to excess, is socially approved sometimes one starts to ….wonder.

This is not a post about how to find help or how to diagnose an addiction or substance dependence problem. Information is out there from many Internet sources, although I will say that self-diagnosis or amateur diagnosis has some severe limits. Best to involve the professionals.
And this is really the lead in. The substance abuse professionals have very low exposure to the target population of people who need evaluation. Consider the basic medical checkup / screening for all variety of ailments. Metrics for potential diabetes problems, breast cancer, colon cancer, various latent infections, cardiac problems, hypertension….the list goes on. The medical profession goes through all the established steps depending on your stage of life and various risk categories. Anything slightly suspicious turns up and, bam, right on to further diagnostics to find out what is UP with your health.
Oh, don’t worry, they screen for substance abuse problems too. But here’s the difference. Substance abusers lie like rugs. You think that a woman who has a suspicious lump is going to untruthfully say “Oh, c’mon now doc, I’ve had that thing for years”? Hell no. Substance abusers are much more likely to actively put healthcare professionals off the track by underreporting their use.
As PalMD recently explored in a post, invasive confirmatory tests on blood or hair samples for evidence of a substance abuse problem are not considered pedestrian procedures.
There are many, many other problems standing in the way of the substance abuse profession coming to bear on the population that needs their help. Some of it is captured in health insurance parity issues in which insurance may not cover addictive disorders. There is the deeply entrenched problem of addiction denial. No, not the individual saying they can stop anytime they want. I mean the covert or overt supposition from the family member to the medical care profession to the legislative process that addiction is not a medical problem. That the addicted individual merely suffers from a lack of moral fiber and should just stop it already. Despite the fact that the best available science tells us that this notion is false it persists.
It is a very, very tangled public health issue.
I come back to the substance user who makes a New Year’s Resolution to cut back. One of the things I’m resolving to do on the blog this coming year is to figure out ways to talk about parity and stigma and the neurobiological basis of addiction productively. I’m still amazed and indeed outraged when people who should know better (scientists and medical doctors) express scientifically under informed views on the topic of substance abuse and dependence. And I have a tendency to beat them up a bit when I do discuss these topics.
I am pondering turning my blogging attention to the basics and to try to figure out ways to talk about these issues that overcome off putting technical jargon. Perhaps to dial back the use of addiction science topics to discuss the science-denial part and think about what best needs to be communicated to more toward less stigma, more parity and better understanding from the concerned family member all the way up to the medical professional and the CongressCritter.
UPDATE: The NIAAA site “Rethinking Drinking” is a good place to start with some practical evaluation of alcohol drinking. It covers the questions of whether your drinking pattern is risky, how to cut down and how to get help, among other topics.
*I wrote this draft at the end of December last year. I never finished it up and published it but I don’t remember why. I don’t know that I lived up to my resolution but I did take some incremental steps toward this goal. For my newer readers, and even some older ones, in case it is not obvious I’m never really sure what I’m doing with all this blogging nonsense. It is a constant evolution.

No Responses Yet to “"Do you think maybe Uncle Joe has a drinking problem?"”

  1. Sutton Says:

    Another thing getting in the way of honest communication between patients and doctors is that it feels increasingly harder to be sure that what is said between doctor and patient will remain confidential from insurance companies.


  2. DuWayne Says:

    While it is certainly helpful to get a professional opinion, the best first line of addiction diagnosis is introspection. There is no danger of external retribution or judgment, to consider your own behaviors. And the questions you need to ask yourself are basic and minimal.
    Do I have control over my use of x? How often do I use x? Do I use x when it is inappropriate to be under the influence? Am I causing myself significant harm by using x? Is my use of x causing harm to others? Do I lie about my use of x?
    Introspection along these lines is an excellent starting point, as it accepting that answering yes does not mean you are a bad or immoral person. It just means you might need help…


  3. microfool Says:

    You did write a similar article to this one last year, and last year’s commenter joking aside, I appreciate your thoughtful discussion of the issues. If more people started asking (and honestly answering) DuWayne’s questions of themselves with regard to EtOH, weed, coffee, and food, I would hope people could find a more sympathetic or empathetic understanding of addiction.


  4. Pinus Says:

    that is the problem, µFool….people are not honest with themselves…this is one of the hallmarks of the disease.


  5. k8 Says:

    And why is denial one of the halmarks of the disease? Because of the stigma of morality attached to it. If addiction were treated like every other medical problem, would someone be so adverse to getting help? Perhaps. Perhaps not. It’s worth looking in to. Having just finished assisting an undergraduate student with her research paper on alcoholism, it has become increasingly clear to me that there is no definitive research on addiction that leads to any conclusions on it’s treatment. There have been studies done here and there, but nothing conclusive. For a disease that’s been around since people started ingesting things to make themselves feel better, that’s a pretty sad state of affairs.
    Heck, the argument that addiction is not really a disease is still not over. I’ve seen it on scienceblogs all over the place. And you’re people with advanced degrees. Who don’t believe it.


  6. DrugMonkey Says:

    k8, I would like to correct your impression slightly. The notion that studies have been “done here and there, but nothing conclusive” suggests minimal effort. Not so. There is a huge amount of scientific investigation devoted to substance abuse. It is a hugely intractable problem. Hugely. Our lack of success should be viewed as a result of this, rather than a lack of trying. (IMO, of course)
    Now admittedly, we’ve been lacking the BigPharma part of the equation because, presumably, they don’t believe there is a paying market for, say, chronic drug treatment for substance abuse. And this does very much have to do with parity. Funding parity, insurance parity, medical parity.


  7. k8 Says:

    I do agree with your correction. It is not for the lack of trying by well qualified scientists with a passion for substance abuse research. Most of the studies we read ended with, “And then we threw up our hands because we didn’t learn anything.” Which was horribly saddening.
    I also believe that there is a serious lack of funding for said research because of it’s intractable nature and the stigma of addiction. Why throw money at something that can’t be cured? Or something that is perhaps viewed (still) as a moral problem? And why bother trying to save them (insurance parity/medical parity) when it’s something they’ve “done to themselves.”
    I am involved in a community recovery effort that speaks to exactly what you are pondering. Putting addiction in layman’s terms, seeing where the stigma lies, combating insurance and medical parity and coming together to demand increased funding. http://www.faceitsiouxfalls.org/
    I’m not ever confused when I speak to a person off the street with no knowledge about addiction and hear them talk about addiction as a moral problem. I am confused when I hear highly educated scientists and doctors refuse to accept the research that HAS been done. The science is sitting right in front of you and you choose not to believe it. That kills my inquisitive spirit and makes me wonder who my scientists really are.
    If anything, I’m very excited to read where your posts go on this topic.


  8. DuWayne Says:

    Actually Pinus, people are either flat out deluded (which is plenty common) or they are simply lying to other people when the topic is broached. It is quite literally impossible to be dishonest with oneself.
    That said, the level of delusion is somewhat amazing. It is really easy to convince oneself, for example, that if you refuse to listen to anyone explaining the signs, you can pretend none of it applies to you. The problem with maintaining the delusion, is that once you actually notice that some of these apply to you, you are really unable to truly maintain the delusion. That doesn’t mean people always admit they have a problem or even accept that what they are dealing with qualifies as addiction – they just refuse to acknowledge it and refuse to discuss it with a professional.
    I would also note that a “professional” opinion is not always that much better than a layperson’s. Pyschiatrists, psychologists and MDs with a lot of experience dealing with addicts are the only people who are going to provide more valuable insight than an experienced layperson can. It really isn’t as simple as just looking at a pattern of behavior and saying that it crosses some line from habitual use into substance abuse on into addiction. In some locations the distinction may be political – the services available may be contingent on the exact nature of the diagnosis. Beyond that the difference can be important, because it denotes the severity of the problem and proportionally how difficult it will be to deal with.
    k8 –
    The difficulty with definitive research into treatment, is that not all addiction is the same. It occurs to me that a good comparison is cancer. There will never be a magical bullet that cures all cancer, because cancer is a lot of different, yet similar diseases. The same is true of addiction.
    The problem I have with deciding that this or that treatment is somehow superior, is that we tend to want to drop everything else in the face of it. The problem with that and addiction, is that dropping treatment options isn’t a reasonable approach, when we don’t know that that treatment may not be the very best treatment for certain types of addiction – possibly the only treatment that is likely to work for certain people.
    Honestly, I think the best thing to do, is to try to change the social addiction paradigm. Get people away from moralizing it and get them to accept that at the core, ever addiction is an illness – even if it doesn’t fit the traditional disease model of addiction (which I would argue is probably most addiction). The problem is that our society likes to pretend that addiction is a fringe element, that the behaviors of addiction are a fringe, when they are most certainly not. Addiction and the behaviors of addiction are very much a part of the mainstream of society.
    The only substantive difference between addiction and the ingrained habits that most everybody has, is harm and the degree of harm caused by said habit. It really is that simple. If we are willing and able to recognize that, it becomes a lot harder to moralize and demonize. Humans are very inclined towards the behaviors of addiction. It’s just that most people don’t engage in habitual behaviors that cause the harms that addictions do – which is not to say that there are not a whole lot of people who do, many more people than most of us would like to imagine.
    Tearing down stigma would make a huge damned difference, when it comes to recognizing, seeking help for and finding successful treatment for addiction. That and recognizing that addiction is a group of illnesses, not just one.


  9. Jesse Says:

    Isn’t one of the problems that many things people are addicted to are illegal, and admitting it could lead to arrest and prison?
    I mean, that seems to me one giant big honking reason to lie, even to your doctor. Forget the insurance company, what about the cops? I certainly would not trust anyone not to rat me out if I were taking heroin, you know?
    Whether you go to prison also seems to be dependent on how rich and famous you are. Rock star has a heroin problem? He goes to rehab. Poor person has one? He goes to jail forever.


  10. DuWayne Says:

    The unfortunate thing about that Jesse, is that while that is a common perception, it is very unlikely that one would go to jail at all for use. On the off chance that one does, it is even more unlikely to be for more than 48-72 hours, that assuming they are arrested on a weekend. In a lot of larger urban centers, the jails are so very crowded they often just book users through with a charge of possession and they are out in a matter of a couple of hours.
    Of course that is also part of the public record. This can and often enough does have an impact on career, family and other interpersonal relationships.
    As an aside, you have the same expectation of privacy with your MD, that you would have with a therapist. Unless you admit to doing something that puts others in immediate danger (ie. “I am going to go to x’s house and shoot him in the head.”), they are ethically and I believe legally obligated to keep that to themselves.
    On the other hand, when it comes to lay substance abuse treatment, you are safe by virtue of the commitment that addiction counselors have to helping people with addiction and abuse problems. While there are always going to be exceptions, people who work with addicts are almost always in it for very compelling, non-financial reasons. The money really isn’t very good and it really fucking sucks a great deal of the time. It is a profession where you simply have to accept that a lack of successful treatment is a matter of course and that failure has very human and very horrible consequences.
    The odds of getting into trouble because one is an addict seeking help is truly negligible. In a great many places, the cops themselves are actively encouraged, if not ordered to divert users into treatment options.
    Please understand that I am most certainly not apologizing for the status quo. I am a firm believer in legalization and a complete overhaul of public policy and public perception of addiction and drug use. I just wanted to point out that the status quo is not what a lot of people seem to think it is.


  11. pinus Says:

    “It is quite literally impossible to be dishonest with oneself.”
    Well DuWayne, I am afraid that we will just have to disagree here…because I think that is actually very common.
    And also..speaking to the point that we don’t know much about the disease of alcoholism. I think that the last 15 or so years have been really fruitful in terms of understanding mechanisms of the disease. I know of at least one clinical trial for a medication based on these advances (CRF-R1 antagonist for the aficionados)….so there is progress being made…but yes, there is still much to be known…and it will take a special breed of person to take that science and put it to work for patients.


  12. DuWayne Says:

    Pinus –
    There is a reason I said that people delude themselves – they do and it is common. But actually lying to oneself really is impossible. When you know the truth, it doesn’t matter how much you deny that truth – you still know it. And the distinction is important, because while self-delusion is common when talking about addiction, so is lying to others. The bottom line is that a lot of people who you might judge to be lying to themselves, are doing no such thing. They damned well know they have a problem and are banking on the excuse of self-delusion or lying to themselves, to insulate themselves from needing to do something about it when they are called on it.
    The problems with the notion that we are making great strides with the disease of alcoholism, is that there is no singular disease of alcoholism. There are often some common mechanisms and a large percentage of alcoholics do fit within a particular model of alcoholism, but it is important to recognize that not all addiction is the same – regardless of the drug in question. This is important because different addictions often require different treatments.


  13. pinus Says:

    I agree, alcoholism has many different flavors, and not all treatments will work on all people. I am with you there completely, in fact, this is an area of research that I am actively part of.
    But….there is work like this that is hitting the clinic…For example, some great work (that I am in no way involved in) shows that naltrexone works very well in a certain type of alcoholic…but not others. So yes…the hope is that as we learn the different mechanisms/molecules involved, we can use that knowledge to develop more individualized treatments.


  14. Jesse Says:

    Sometimes that perception is rooted in a little bit of truth. I mean, here’s what can happen: you or a loved one has a drug problem. You go to get help. The only way to get it (and to get it covered) is to have some “proof” — some event. Aside from getting arrested for drug use, you have to be screwed up enough to get admitted, and by that time, well, you get the idea. This assumes that the insurance will even touch you.
    Or: you went to a local center to get help for a drug problem. The cops do their thing of watching the folks who walk out, and using that as a pretext to pick them up later when they are doing something “suspicious.” It helps if you are black or latino. (That just about guarantees arrest, and maybe even getting shot as a bonus). The cops are not hanging out in front of the Betty Ford center.
    And you underestimate the time you spend in jail. Posession in this state gets you years unless you have a good lawyer. And if you are poor, well, you are out of luck. Riker’s is full of people like that. And possession means the cop decides he wants to arrest you. Most folks have no power whatsoever in that situation.
    That’s the kind of stuff I am talking about. As it is, there are simply gigantic disincentives for seeking help with a drug problem.


  15. SurgPA Says:

    Ok Jesse, you lost me on this one. First, you don’t need “proof – some event” to get substance abuse coverage. If your insurance (assuming you have insurance – if not then your argument is moot)covers substance abuse (often lumped with mental health disorders more broadly), then it most likely operates on a self-referral basis. Second, please show me any statistics to support your claim that cops “do their thing” of targeting substance abuse treatment centers. What proportion of substance abuse patients is arrested as a result of being tailed from the center? I’m not even sure that most addictions are to illegal substances (#9). Are you discounting alcohol and tobacco, both of which are generally legal, albeit with age limits?


  16. Jesse Says:

    I wasn’t counting the legal substance abuse stuff, just saying that in cases where you have a problem with something illegal, getting help is really problematic because you are addicted to something illegal. That means you are essentially admitting to illegal activity, and going in for treatment — I mean, have you ever dealt with an insurance company in those cases? I’ve seen what these guys ask for — again, they are asking you to put to paper that you have a problem that could potentially land you in jail (to say nothing of what happens at your job). Would you do that? How much do you trust the rep from UnitedHeath, assuming you even have insurance?
    Christ, have you seen how the cops shake down drug addicts? Where have you been?


  17. DuWayne Says:

    I am totally sorry Jesse, I was engaging in hyperbole and you happen to live in what is quite possibly the very worse place in the U.S. for drug crimes. That is not to say that what you describe doesn’t happen in other places, but it is rare, even in the south. Most cities have strict policies about cops staying away from treatment centers.
    SurgPA –
    Ummm, it’s kind of hard to keep statistics about cops watching treatment centers, needle exchanges and methadone clinics for the poor. The best evidence that it happens, is that a lot of cities have passed resolutions or department policies to prevent the cops from doing so.
    And unfortunately, NYC (a place I have not paid much attention to lately, but will) is particularly nasty to illicit drug users. I don’t believe it is the least bit of an exaggeration to assert that there isn’t a worse city in the U.S. to get busted for possession for personal use.


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