My patient smiled a toothless grin and told me, "I feel fine, doc." But he was far from it. His liver enzymes had risen into the thousands, his skin was a pasty yellow I didn't need the benefit of sunlight to see, and his albumin (a protein whose level indicates the liver's functional capacity as well as a patient's degree of malnutrition) had fallen far too low. Further, he'd been admitted to the hospital with a chief complaint of vomiting blood, which turned out to have been caused by esophageal varices, a potentially life-threatening condition seen in end-stage alcoholics.
"How often would you say you drink alcohol?" I asked him.
"Oh, once in a while. You know..."
After a pause, he admitted, "Yeah, I'd say that's about right."
"What do you like to drink most? Beer? Wine? Whiskey?"
"Yeah," was his only reply, which I took to mean he liked all three.
"How many drinks do you usually have a day? Ten? Twenty?"
"No! Not twenty!" He laughed as if we were on the inside of the same joke. "Not twenty, no sir!"
Another pause. "Maybe ten..."
By the time we'd finished our conversation, I'd learned he drank beer (about a 6-pack), whiskey (2-3 shots), and vodka in some combination every day and had been doing so for about 20 years. He used cocaine sometimes, too.
He was easy going and friendly, always ready with the same smile every time my team and I entered his room. But then on hospital day #4 he started vomiting up blood again, soaking his hospital gown and sheets, so we had to transfer him to the intensive care unit. Unfortunately, once there his bleeding accelerated, so the team placed a Sengstaken-Blakemore tube down his esophagus and inflated it against his varices (analogous to the way you'd hold pressure against a cut finger). Despite their best efforts, however, he died the next day, literally choking on his own blood.
Alcoholism is broadly defined as a chronic illness characterized by continued drinking in the face of adverse consequences. It's progressive and often fatal. You can generally identify an alcoholic by their preoccupation with alcohol, their inability to control their drinking, and their denial that they have a problem with alcohol at all. However, one of the most important things to know about alcoholics—or addicts of any kind, actually—is this: they lie. Nothing is more important to them than their addiction and they will do anything to maintain it. Though many exceptions exist, most commonly an alcoholic's life self-destructs in roughly the following sequence: interpersonal, legal, financial, medical, and finally occupational. Though no definitive proof exists yet that alcoholism has a genetic component, circumstantial evidence abounds. For example:
There is no known cure for alcoholism, but there is a guaranteed way to avoid all of its adverse consequences: abstinence. Some might argue that truly addicted substance abusers have little or no free will with which to resist their addiction, but if we believe that we're left without a way to explain how so many alcoholics do actually succeed in achieving life-long abstinence.
Because so many of them do. These alcoholics are considered "recovered" or "recovering" (depending on your preference for referring to their decision to stop drinking once and for all or to the ongoing process they use to maintain abstinence), and they look just like you and me. If your neighbor isn't one of them, your neighbor's neighbor probably is. The prevalence of alcoholism varies by country but in the U.S. it's estimated to be between 5-10%. That means one out of every ten or twenty people you know is an alcoholic, whether you (or they) know it or not. My patient was among the worst of the worst I've seen and represents the image most people—and even most doctors—have of alcoholics in general. But this image is a mirage, representing only one segment of alcoholics in our society. Some recovered alcoholics go on to become incredibly successful. In fact, recovered alcoholics may even be more successful than non-alcoholics as a group. Though I know of no data that proves this, there are several reasons to think it might be true: recovered alcoholics in general have learned to make good use of fear and are perhaps more comfortable taking risks and therefore more entrepreneurial as a result. Or perhaps it's because they have a faith in a "higher power" they find truly sustaining during difficult times. Whatever the reason, recovered alcoholics can be found running everything from large companies to large countries (though how well is certainly a matter of contention).
Even if your neighbor isn't literally an alcoholic, he or she is undoubtedly a metaphorical one: like a recovered alcoholic, your neighbor has problems you don't get to see. Most people we encounter in the course of our day seem on the surface to be living relatively calm, functional—even happy—lives. And some certainly are. But many are not. Not that most people intentionally work to create such a facade. Rather, most people simply work to carry out their responsibilities as best they can. Which isn't to imply everyone is a fragile reed at risk for breaking when the mildest of winds blows either. Just that people often appear more composed and together than they actually are, unintentionally fooling the rest of us into believing their polished surfaces reflect equally polished inner lives—polished inner lives we know ourselves to be lacking.
But don't be fooled into thinking your neighbors have a secret power you don't. If you stopped everyone you met in the course of a single day and asked them to tell you about their most pressing worry, you'd find yourself astounded not just by the sheer intensity of the suffering people live with silently every day but by their ability to live in spite of it. In this sense, we're all like alcoholics (not to minimize the incredible and unique difficulty of overcoming a literal addiction to alcohol)—all struggling with problems we don't routinely broadcast to the world. My problems may not be yours, and your problems may or may not include a problem with alcohol, but no one's problems make them something more or less than anyone else.
I was reminded of how often we forget this when I watched my team interacting with my patient before he died. They all cared a great deal about what happened to him, wanted him to live, and worked hard to save him. But they all seemed to presume a great distance separated his life from theirs, as if there were some fundamental difference between the problems he faced and their own.
But whether a recovered alcoholic or not, a doctor or a patient, you or your neighbor—no real difference exists. It's a surprisingly difficult truth to believe. I still struggle to remember it myself when I get mad at someone and feel the urge to slander them or look down on them, the way people still do alcoholics, or for that matter anyone who struggles with problems they're not struggling with themselves. At those times I try to remind myself that everyone has a point of view, that everyone has dreams they carry in their heart and situations they fear yet struggle against. Maybe if everyone were a little more interested in understanding one another rather than in comparing themselves to one another someone might have appeared in my patient's life in time to provide the support he needed to overcome his addiction. Though such support certainly wouldn't have been by itself sufficient, I think it would have made success more likely. I'm reasonably confident no such support ever came his way, though. After he died, no one ever came in to claim him.
Dr. Lickerman's new book The Undefeated Mind: On the Science of Constructing an Indestructible Self is available now. Please read the sample chapter and visit Amazon or Barnes & Noble to order your copy today!