Every bell curve has two ends.

The face is rosy and pink

The patient is back from the brink

            I have to say,

            They’re walking away

From their dope, their soda, and drink

Years ago in residency I talked to a college friend during the throes of his first divorce.  The conversation went for an hour an a half (at a time when long distance phone service in the course of a year would equal three or four months rent).  I correctly diagnosed the estranging young woman as alcoholic, and I warned, “When she comes crawling back to you in six months, which she will, do not take her back.  In fact, do not take her back until she has six months sobriety with AA.”  I was right about when she would come crawling back, but as near as we can tell, she never got into AA.  I was pretty adamant about AA being the only way out of alcoholism.

Not so much any more.  I’ve seen a bunch of pretty heavy drinking men get sober permanently with the birth of their first child.  I seen a lot of women walk away from the sauce about the time of their first pregnancy and never go back.  One very bright patient who worked a dead end job and drank most nights in the early nineties.  With the advent of a good job, the drinking stopped.  Religion, marriage and family followed successively, over the course of a year and a half.  I have not seen that patient for the last seven years, probably because of illness avoided.

Most, but not all, alcoholics need a spiritual transformation to quit drinking.  Some would call that spiritual transformation “getting religion” but sometimes it doesn’t involve religion at all, just a really good shrink.  A few have stopped with acupuncture, others have stopped with Revia or Campral. And there are a very, very few who manage to just walk away from it. 

When I was in Navajoland, most alcoholics stopped drinking  between the ages of 40 and 50 with no treatment, religion, or intervention.  In fact, it was a rare Navajo alcoholic who drank after age 50 unless their brain was so fried that they couldn’t remember what happened five minutes ago (it’s called the three item five minute test, and it taxed my skills in Navajo language).

On the other side of the spectrum are those who are instantly addicted to alcohol with their first drink, and drink themselves to death before age 21. I saw a case like that many years ago.  When the person says, “I am an alcoholic, and I know I’m killing myself, and that’s the way I want to die,” I treat them as I treat any patient with any terminal illness.  And after they die, I treat the fallout in the family for a couple of generations. 

Thus alcoholism is a spectrum disease, and any model of it must take into account both ends of the bell curve.

Comorbidity (other diseases existing in the same patient at the same time) always has to be taken into account.  Bipolar disease, chronic depression, and schizophrenia make treating alcoholism difficult, just as they complicate the treatment of heart disease, high blood pressure, and diabetes.

A patient today appeared to have walked away from decades of poly drug abuse (marijuana, alcohol, caffeine) with no problem.  The person is back exercising and playing sports, feeling better than ever, and with no more intervention from me than saying, “OK, how much is this costing you in terms of money and time and body parts?” Today the blood pressure was better, the weight down, the complexion clearer, and the smile bright.

Twenty years ago I would have pushed the twelve-step agenda harder.  Now, it’s like most other non malignant disease processes: try the simple thing first and see how the patient does.

Most addicted patients don’t do well with the plan they’ve been trying, but if they’re willing to tweak the approach I’m willing to support them in their efforts, for a while.

Once I read back to the patient their seventeen successive promises to quit over the course of five years.  The patient hasn’t had a drink for the last eleven years.  I don’t see him nearly as often.

It’s like every other disease I treat, there’s always a pharmacologic and a non-pharmacologic approach.  Sometimes the non-pharmacologic approach is obvious (taking out ear wax or stitching a wound) and sometimes it’s absurd (don’t tell a patient experiencing a heart attack to “read this book”).

Most diseases come in spectrums.  People at one end of the bell curve do not behave like people at the other end of the bell curve.

The same principle holds for most of human behavior.  Every successful model involving people will take into account human variability.  Marxism failed because it did not take into account the tendency of humans to laziness and greed.  Capitalism ignores the force of altruism.


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One Response to “Every bell curve has two ends.”

  1. 2010 in review « Walkaboutdoc's Blog Says:

    […] Every bell curve has two ends. March 2010 3 […]

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