Sunday, July 7, 2013

How Much Is Too Much?

There is joke among doctors, "What is an alcoholic?" "Someone who drinks more than his doctor."

Recently, a friend was injured when he fell following an evening of drinking. While his injury was fairly significant, thankfully there shouldn't be any long-term physical sequelae. This isn't about him.

What has been fascinating [is that the right word? Interesting? Challenging?] has been the ripples of responses within our circle of friends. There are all varieties of drinkers amongst my friends. Some barely drink at all. Some drink fairly impressive amounts on a regular basis. A few have discriminating tastes, and they take pride in their knowledge of variety of wines, crafted cocktails, and high end beers. Others have palates which are not so picky. Equally diverse has been the reactions following our friend's injury. Some barely acknowledge that anything happened. Some have considerably curtailed their own drinking, whether consciously or not. It seems like a few have even doubled down and picked up the pace.

Which leads me to the question I posed in this post, "How much is too much?"

As a physician, I've often struggled with this question. In rehabilitation, we often care for people who have had serious injuries caused by alcohol, as consequences of their own drinking or someone else's. I've care for people with head injuries, spinal cord injuries, severe fractures, liver failure, and burns. With each patient, I am stunned how quickly a life can change in a moment of bad judgment. After such an injury, however, my role is fairly clear cut.

What to say to people who haven't (yet) been affected? In my outpatient practice, it is fairly routine to ask people about smoking and drinking habits during an evaluation. These are people who may be coming to me for neck pain, tendon problems, sports injuries, or arthritis. What should be my flag to act on the information I collect and express concern about alcohol?

One might think that there is consensus among the healthcare professions about guidelines for alcohol consumption. I'll be the first to acknowledge that I am not an expert. There are guidelines which indicate amounts that may be beneficial for one organ systems, but often they conflict with guidelines for amounts that could harm a different organ. There is disagreement about how guidelines should be adjusted for gender or body weight. Genetics can influence how well people process alcohol, and they seem to influence who is at risk for addiction. Honestly, even if I knew how to weigh all of these different factors, I don't think I could effectively do that during a clinical encounter when I'm supposed to be treating knee pain.

I have equal confusion in a social context. There often is not a good correlation between the people who drink a lot and the people who suffer consequences from drinking. That makes it hard to rally support to intervene, when the people needed to help with an intervention may actually drink more than the person who really has a problem. Then, there is not even great agreement about what constitutes the best help: programs that advocate abstinence or ones that focus on harm reduction? Programs that are professionally based or community-volunteer led?

I really struggle with this both professionally and personally. I want to be a good physician and a good friend. I want to be an effective resource and advocate. How do I distinguish who needs help from those who are simply enjoying a vice responsibly? Then, how do I help? I know there are no easy answers to any of this. I have been struggling with the questions of how alcohol (and other substances) fit within a social milieu since college. It just feels more acute, more emotional, right now having had a friend get hurt.

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