It seemed like such a great idea at the time… His name is Darin. Of course, that’s not his real name, but he is a casual friend of mine. A bright young man, possessed of good looks, a warm smile, and a soft-spoken demeanor. Darin is brilliant with computers — not merely competent, as many are, but a true geek, tear-’em-down-and-rebuild-’em smart, fearless in the depths of sockets and motherboards, Windows registries and Unix terminals. A true success story, you might say, bright future, make some girl very happy. But Darin was toolin’ down the freeway of goin’ nowhere fast. You see, Darin had a little problem: a fondness for the grape and the snort which always seemed to get the best of him. Not that he didn’t try: he was in and out of AA rooms more often than a pastor’s wife at church socials, always returning beaten and remorseful, determined to do better this time. “This time” rarely lasted more than a few weeks or months. Darin was quiet, but a man of passion. He was always in love. Intoxicated with the flush of a new romance, that rush of euphoria so real yet so maddeningly transient. Each new girl was “the one”, but nights of passionate, drug-enhanced sex soon proved impotent to overcome the waning charm of Miss Demeanor, the rumpled sheets, and the rumblings of his restless soul. Before long he was again cruising for some other codependent wench, herself seeking a sodden soul to save. Like an ugly tie wrapped up pretty under the Christmas tree, Darin’s package looked good at first glance, but he quickly proved to be a daddy’s nightmare: “no phone, no food, no rent”, as the song goes. Soon he was once again welcome only in his mother’s house, with whom he could do no wrong. Unfortunately, the same could not be said of Darin: someone did him dirty, stiffing him out of a good deal of cash, and forgiveness was not one of his many charms. The details are murky: a computer built or repaired, promises made but not kept. There was much lighthearted chatter at the coffee houses — was it Darin’s fault, or his nemesis? No matter — like a quiet bubbling cauldron in a witch’s lair, Darin was cooking up his favorite dish: a rip-roaring resentment. Not visible on the outside, of course, but raging like a Jerry Springer slugfest in the conference rooms of his mind. It was the perfect mixed drink: a perceived injustice blended with that unique obsessiveness which addicts possess seemingly in endless measure. It is not clear when the brainstorm struck — an idea so brilliant, so flawless, that it would right all injustices and settle all disputes: Darin would break into his detractor’s home and steal back the computer which tortured him so. No mere larceny, mind you, but the picture-perfect crime, a liberation to rival Paris in ’45. Carefully timed when the enemy was not at home, staged so not even Sherlock Holmes would presume that Darin might be the perpetrator. Sweet revenge, sweetly executed. Like tightly-written computer code, Darin’s nimble mind set the parameters, checked the variables, and executed commands in a tight loop whose efficiency and speed wasted no cycles. The Day of Vengeance arrived, with only one small ingredient missing: courage. But Darin had that algorithm factored as well: a fifth of Vodka erased all fears, drowning all doubts. By stealth of night, with watches synchronized and bottle drained, the window glass parted to usher him to glory. The mission was underway. No one knows whether anyone heard the shattering of glass, but despite his stealth the disruption somehow caught the notice of neighbors. When the police arrived, the cause of the disturbance became evident: there was Darin, passed out on the floor, beside the untouched computer he coveted. Fate had struck a cruel blow — his celebratory blackout had arrived on the wings of Mercury rather than with the spoils of Mars. He awakened to handcuffs and an open-ended reservation at the Gray Bar Hotel. All good stories — even true ones — should have a moral, but Darin’s story eludes easy lessons. He was taken by that peculiar insanity which alcoholics possess in abundance, even while sober. When Darin hatched his master plan, he was not drinking, but engaged in one of his countless attempts to clean up. For the alcoholic, the danger lies not in the bottle, but in the brain. The sane among us make mistakes, to be sure: wisdom comes from experience, and experience often comes from lack of wisdom. But facing the inevitable consequences of bad choices, we generally rearrange our lives and priorities to ensure that such a travesty does not happen again. Not so the alcoholic. Obsessively repeating behavior long ago proven destructive, he nevertheless pursues the optimism of denial which says the next time will be different. This baffling disconnect from reality cascades from farce to tragedy, as the alcoholic perceives no problems other than those bastards who are out to get him. There is much resistance to the idea that alcoholism and addiction are a disease. Much of this comes from conservatives, and those of religious conviction, whose proper emphasis on personal responsibility and moral rectitude sees in the alcoholic only reckless hedonism and wanton irresponsibility. These qualities the addict has in spades, but less obvious is the driving obsessive compulsion, the thought disorder which is their engine. The medical evidence for the disease model of alcoholism and addiction is deep and wide, as I have detailed in part elsewhere (see also this and this for more on the topic). The liberals have this one right: the alcoholic is a victim of his or her genetics, and the addition of a mind-altering drug — which one is probably moot — starts a swirling whirlpool whose vortex holds only misery, destruction and death. Not many survive its power. Yet defining deviance from normal as disease also has…
Category: Medicine
General essays on the topic of medicine and the medical profession
2. Judging Addiction
Some time back, while listening to a sports radio host who was discussing a athlete whose career had been terminated for drug use. The host was using it as a segue into his philosophy, of the libertarian persuasion, about drug laws, enforcement, legalization and addiction. His conclusion, in essence, was that all this discussion about “diseases” such as addiction was an excuse to avoid personal responsibility and create victims — addiction was, pure and simple, a personal choice made by individuals, who could just as easily choose to give it up and live responsible, upright lives. It’s a sentiment I hear commonly. And it’s wildly off target. First of all, why talk about addiction now? As a physician, I’ve been interested in the problem of addiction and alcoholism for many years, even though it’s not my main area of specialty. Like most physicians, I have had to sort out patients with legitimate need for potentially addictive medications, such as opiates, from those seeking the same drugs for different, abusive reasons. This might seem easy at first glance, but those with drug addiction are masters at deception — it’s a survival skill, learned through repeated practice. Why does one patient get a prescription for pain pills, take a few, hate the way they it makes them feel, and flush them down the toilet, while the next fellow gets the same prescription, triples the dose, tells you he “lost the prescription”, and demand more in a few days? It’s easy to blame this on irresponsible hedonism, but it’s nowhere near that simple. Secondly, I have many friends who are in recovery from drug and alcohol addiction, and have spent quite a few hours discussing and understanding their histories, behavior, and the recovery process. There is no better way to shatter misconceptions about alcoholism and addiction than to go to the source: those who’ve walked through hell and survived to reclaim their lives and tell their stories. Lastly, the solution to the problem of addiction is, somewhat surprisingly, far more spiritual than medical or sociological in nature. Hence, it is a natural for a site on medicine, religion, and culture. I plan on writing a series of articles on aspects of this topic, since there is a lot of ground to cover. Libertarians and liberals should not feel too smug just yet — they’ve pretty much got it wrong as well. More on that later. First let’s address the issue of the “disease” of alcoholism and addiction. I use scare quotes because that is the way many people, especially those of the conservative bent, view this problem as a pseudo-disease fabricated from thin air by psychologists and social workers, to create another class of victims in need of a big-government fix. Those who pride themselves on their reliance on logic, reason and tough love over emotion, feelings, and faux compassion, have abandoned science and objective truth on this subject, however. The simple fact is that medical science is rock-solid in conclusion that alcoholism and addiction are well-established disease processes, comprised of genetic, physiologic, and mental illness components. There is a vast amount of medical literature addressing this disease in its many medical, psychological, behavioral and social aspects. To summarize some of the evidence: Family History: Children of alcoholics are far more likely to become alcoholics. This is true even when adopted at birth by non-alcoholic parents. Genetics: Specific genes have been identified which influence the metabolism and psychological effects of drugs and alcohol. Alcoholics and non-alcoholics metabolize the drug differently because of differences in the enzyme aldehyde dehydrogenase; a neuropeptide Y gene mutation is associated with higher incidence of alcoholism; a gene expressing the gamma opiate receptor, when mutated, is associated with a higher risk of heroin addiction. Many other such genes have been identified related to cannabis, codeine, nicotine, and other addictive substances Animal Research: Specific genetic modifications in mice can reproduce or block addictive behavior. Neurophysiology: Addictive drugs have profound effects on critical neurotransmitters, such as dopamine and GABA, which are long-lasting and have profound impact on affect, behavior, and thought processes. The point here is not to bore with excessive medical details, but to emphasize that the addict is different: physically, genetically, biochemically, mentally. They are not simply wanton hedonists who wake up one day and decide to live a life of pleasure-seeking and irresponsibility, and can just as easily wake up and decide to stop. No doubt some — perhaps even many — enter the world of alcoholism and addiction by means of such ignoble motives. But once ensnared, their journey back to sanity and wholeness without drugs, even if pursued with passionate willfulness and desperation due to a destroyed life, faces enormous challenges inherent in their genetic, biochemical, and mental liabilities. And many enter the slavery of addiction through otherwise legitimate portals, such as social drinking or legitimate prescription use. The addict is in many ways a hidden time bomb waiting to detonate. Yet society in general is entirely justified in seeking and demanding solutions to the problem of addiction. Addiction plays a major role in virtually every social disruption we face: divorce, homelessness, inner city crime and gangs, child and spousal abuse and neglect, unemployment, poverty. It has engendered an enormous illegal industry which corrupts entire countries and funnels vast amounts of money to crime and terrorism. But to find a solution to such daunting challenges it is imperative that our understanding of the problem be one of clarity and truth, not prejudice and false premises. Solving the addiction crisis by demanding personal responsibility may feel good, but does not begin to solve the problem. Personal responsibility is a result of recovery from addiction and alcoholism, but an ineffective means to accomplish it. Surprisingly, the real answer comes from the spiritual rather than the will.
My Favorite Medical Myths
A recent discussion regarding access to health care caught my eye. Like many such posts, there was a brisk repartee in the comment section on the topic of fixing our daunting health care access problems. Many of the comments were knowledgeable and informative; some, as is always the case, were idiotic or pedantic. One comment in particular, however, caught my eye, posted by a fellow from the progressive side of the political spectrum. It was a rather lengthy screed, which is excerpted here only in part: I notice that people who enjoy making reflexive attacks on any and every possible change in the current system have this one thing in common: They love to mock the idea of preventive medicine. … One other point that isn’t being made by the right wing: The number of students accepted by American medical schools was increased substantially about a third of a century ago (partly by the opening of more campuses by state schools), and then was held static. Some attribute this freeze to pressure from the medical lobby (it creates an artificial scarcity of doctors). We should increase entry level spots in medical schools by fifty percent or so (i.e.: what we did in the ’70s etc), and open many more spaces in nursing schools. Curiously, the federal government could cover the tuition of every medical student in the country for a small fraction of what we spend on medical care in total, and it would solve some serious problems for the rest of us by taking the financial bind off the entry level physician… Of course none of this is all that hard to figure out. The major paradigm shift occurs if you stop thinking about medical care as the exercise of market place free enterprise in which doctors compete to make the most money, and instead view it as a public necessity. Now, my intent is not to beat up the poor fellow; he is, after all, a progressive, and therefore possessed of a profoundly misguided understanding of human nature and motivation, and a strong inherent (and incoherent) proclivity for finding in government the solution to every imaginable problem. He is more to be pitied than censured. But his comment prompted me to begin thinking about some of the more common medical myths; those axiomatic convictions which seem to drive every discussion about healthcare policy, and show up in virtually every comment section on a health policy-related post. This particular gentleman’s comment mentions at least two such myths, and therefore provides lush green fodder for a rambling rumination on my part. So here you have it: Some of my very favorite medical myths, time-tested truisms redolent with pertinence and pathos, but replete with error. 1. The healthcare system will save money and lives if we will only focus on preventive medicine. Like all such truisms, this one actually has a grain of truth. There certainly are areas of healthcare where preventive medicine — best defined as measures taken by physicians and patients to prevent disease or detect it early– are clearly beneficial. Some examples which come readily to mind are prenatal care, where careful management of maternal nutrition, blood pressure, blood sugar, and other parameters can have a significant beneficial effect on the health of the baby; pediatric immunization; and screening for early detection of diseases with significant long-term morbidity, such as hypertension, lipid disorders, and diabetes. Beyond such areas, however, the idea of preventive medicine rapidly gets into the realm of wishful thinking, appealing largely to those who believe that doctors make money by keeping you sick, and that organic spinach keeps you healthy (a little e.coli is good for you, after all…). Take, for example, the idea of an annual physical exam. This is widely perceived by patients as an important measure of preventive care, but is an almost entirely worthless exercise. It makes the patient feel better, but completely lacks in evidence of substantial long-term health benefits. Screening tests for cancer are another such area, which not only provide a false sense of security when negative (since many false negatives occur), but also pose a significant risk of their own. This risk arises from the fact that all such tests have a substantial false positive rate, which when multiplied across a population while looking for relatively low-incidence diseases such as cancer, generate an enormous amount of unnecessary cost and potential health risk chasing down abnormal tests in patients who do not have cancer. I have discussed this at somewhat greater length in a prior post on PSA screening. Of course, the other thing which preventive medicine stresses are lifestyle issues: exercise, weight loss, smoking cessation. It should go without saying that there may be one or two individuals on the planet who do not know that you should exercise regularly, lose excess weight, and stop smoking. There may be also one or two folks alive on the planet who have successfully followed such exhortations for more than a week. So how’s that preventive medicine approach workin’ for ya? Oh, and when your preventive screening finds your blood pressure could drive a steam turbine; or that your blood has more sugar than Coca-Cola; or that your arteries look like Crisco from your sky-high cholesterol — guess what you’ll be told: lose weight, stop smoking, get to the gym. That’ll be $100 bucks please, pay the receptionist on your way out. Stay healthy, now! 2. Rich, greedy doctors are bleeding the system dry, — and — 3. The AMA restricts the number of doctors trained to ensure shortage and maintain physician incomes. Well, like many myths, there may be a tiny grain of truth here: There no doubt are a few doctors who drive up healthcare costs by gaming the system; in the medical field, we call these fellows “crooks.” But the harsh reality is this: physician reimbursements make up only about 10 to 15% of total healthcare expenditures. If you can figure out a way to get physicians to…