Mike and the Demon Rum

The recent blogging hiatus is because your humble narrator was off getting married. That is now accomplished. In the calendar year of 2009, I'll have lived for three months in the Third World, moved across country, started a new job, gotten married, and possibly have sold my house (condo). No wonder I feel exhausted. At any rate, I'm committed to getting back in the blogging saddle and putting more ideas into words.

To set today's scene, I'd like you to pretend you're sitting in an emergency room. This is not the bright lights and bustle you see on "ER". A psych emergency center involves small, windowless rooms without furniture, wall fixtures, or much of anything else. You bring in a plastic lawn chair to interview. At the moment, it's about 2 AM, and you're sitting across from a guy we'll call Mike. Mike is here because he's feeling suicidal. He's been here a while; when he came in, he had a blood alcohol of 450, and you've been waiting for him to sober up enough so you can talk. (For reference, at 200 mg/dL, a "normal" person should be staggering, falling-down, blacking-out drunk. At 400, you or I would be comatose and on our way to dead. Mike was walking and talking, albeit incoherently.)

Sometimes Mike is fat, sometimes he's thin. He's usually in his 40s. He often has tattoos. He's always alone. The story has some variations, but in the aggregate, it goes like this: Mike started drinking young. Sometimes his daddy did too. But, at the start, Mike had a job, a wife, usually kids. Eventually, though, he was hitting it harder and harder, and he lost his job. So he went into treatment, finally. That got him sober -- for a few months, tops. Lather, rinse, repeat. After two or three cycles of this, his wife finally left him. He moved around a bit, staying with family and friends, repeatedly trying to get it together. Slowly, inevitably, he burnt out those supports too, and ended up living in his car. When the car stopped running, got stolen, or just plain got lost, he joined the ranks of Seattle's homeless.

Mike has been in every kind of hospital you can imagine. Outpatient chemical dependency treatment. AA. Inpatient treatment, sometimes for months. Sometimes he's even tried aversion therapies, where they forced him to drink while administering a medication that makes it painful to ingest alcohol. In the hospital, he gets clean. He wants to be clean. He really does want to give it a try. But, when he gets released on that final day, he gets nervous. He thinks of all the times he's tried this and it hasn't worked. He thinks of how alone he is now, of everything he's lost. That old, familiar anxiety worries at him, and a few hours later, he's opening that can of beer or that bottle of cheap liquor.

Mike's problem now is that, even though he's on public assistance, the county will only pay for so much inpatient time each year. So, chances of him getting inpatient detox, inpatient alcohol rehab, or even ordinary inpatient psych are pretty slim. Your task now, in the middle of the night, is to figure out what to do with him. He did say he was suicidal -- but according to the notes in the computer, he always gets suicidal when he's been drinking, and wants to live again when he sobers up. There's also the fact that withdrawing from alcohol might kill him. You see, while alcohol might not be as addictive as heroin or crack, it can be far more deadly. Withdrawing from most street drugs is painful, but ultimately just involves feeling like an utter wreck for a week. Withdrawing from alcohol involves tremors and an altered mental state -- the legendary delirium tremens. If your brain is sufficiently dependent on alcohol, we progress to seizures, and then to seizures of the autonomic nervous system that regulates your circulation. Either you get some alcohol in you, you get a sedative that acts on the same receptors, or your wildly-firing brain actually drives your heart to stop beating.

So, in theory, you could just let Mike hang out in the ER for a bit until he decides to leave. He won't seize immediately -- it takes a day or two to get there. If he leaves, he'll drink, which will solve the problem of withdrawal. If you're feeling like he has a good story and you have time to argue on the phone with insurance authorization, maybe you can bring him in. He can get meds to ease withdrawal and taper himself back to sobriety, then get discharged to a halfway house. Of course, if you think you're going to magically break his addiction, you're more delusional than the patients. Alternatively, you can let him go. He'll drink, and eventually he'll be publicly drunk and get arrested. Jail will sober him out and maybe even court-order him back into treatment. That is, assuming he doesn't fall off a wall, or in front of a car, or into the bay. Or drink, get suicidal, and take that final step off the Aurora Avenue Bridge. Options aplenty, but good options are scarce.

Everyone, including Mike, wants him not to drink. The problem is, nobody understands why he does. You or I don't do this. There is something in his neurons, something specifically tuned to alcohol, that pulls him to drink like a magnet. It's not just personal weakness. This is beyond that -- it's a need that's almost as bad as the need to keep breathing. Some of it is certainly inborn. If we caught it early enough, maybe we could have undone the rewiring, kept the brain from learning this deep dependency on the drug. Instead, as Mike kept drinking through his 20s, it burned itself in deeper and deeper. As one after another social support burned out and cut him off, the restoring forces that would pull him back to sobriety disappeared.

There's no moral or easy answer at the end of this story. I don't know what to do with the Mikes who show up at my door. I try to get them referrals, and if they want to come into the hospital, I usually let them. The only thing it really changes is helping me feel like I've done something for a fellow human. It also reminds me why I wanted to be a research psychiatrist as opposed to primarily a clinician -- there's a whole lot of Mike out there, and right now, we're letting them down.