I don’t want to tell alcoholic patients to keep drinking, but I have to
Doctors want good outcomes for our patients, but the reality is that this can’t always be the case. If something bad happens after we’ve done everything we possibly can, it’s hard, but we accept that it’s part of our work. It’s a very different experience if bad things happen when we know that more could have been done.
As an NHS liaison psychiatrist, this is something I face regularly when I see alcoholics who are seeking help – I am often forced to advise them that they must keep drinking alcohol.
Why on earth would a doctor do that? Well, a typical case for me is a patient who has been brought to the emergency department (ED) after trying to end their lives in an intoxicated state. My ED colleagues sort them out from a physical health perspective and the patient is referred to our team for an assessment of their mental health needs. Often, when these patients sober up, they no longer feel suicidal and some of them have no memory of harming themselves. I make a diagnosis of alcohol dependence and often the patient is keen to get help, feeling very scared that their alcohol consumption has caused them to do something so risky. So far, challenging but manageable. But this is when the situation becomes tricky.
The brain of an individual who has been drinking too much for too long becomes physically dependent on alcohol. If they stop drinking suddenly, their brain struggles with this chemical shift and they will develop withdrawal symptoms. For some, this will just be the sweats and shakes; unpleasant but not life-threatening. If the withdrawal of a more heavily dependent drinker is left unchecked, however, it can rapidly descend into a state we refer to as “delirium tremens” which is associated with a high risk of seizures and death, and classified as a medical emergency.
In order to manage the withdrawal safely, patients need to be monitored closely by health professionals and prescribed medications to manage the transition – this is what we refer to as “detox”. Some people are able to undergo detox in the community, but others require inpatient treatment in order to keep them safe.
The problem is that drug and alcohol services, which ordinarily take on this work, are vastly under-resourced. They simply do not have the capacity to see everyone who needs their help in a timely manner. And so patients have to wait. While they do so, they have to keep drinking alcohol in order to avoid a dangerous withdrawal, which in turn often means that they then lose all motivation to get the help they so desperately need. As you can imagine, it’s particularly hard asking this of my patients, for whom a return to drinking increases the risk of suicide.
It’s not just those with substance misuse problems who have to wait for care, of course. We consistently hear stories of how the NHS is buckling under the combination of austerity and rising demand. But if your knee operation has to be cancelled and you are instead offered an appointment in a month’s time, it’s likely to simply be a painful inconvenience. It’s different with addiction.
Anyone who has any real experience of substance misuse will tell you that the biggest hurdle is for the individual to acknowledge that they have a problem and need help. There can be brief moments of opportunity when patients are in the right frame of mind to be receptive to the idea of treatment. If you don’t seize the moment, then the patient descends into the fog of addiction again and the chance to help them is lost.
It’s easy to imagine that this is all just a question of willpower. But developments in neuroscience have shown us that the alcoholic brain functions differently to the non-alcoholic brain – it becomes primed to seek out alcohol, an effect that is potent and long-lasting. Even alcoholics who have been in recovery for several years will attest to the strength of their ongoing cravings. How much harder must it then be for the alcoholic who is still drinking to make the decision to stop? And anyway, how many of us would be capable of making a sensible decision with a litre of vodka coursing through our body? (If that amount sounds fantastical, I can assure you it isn’t.)
At the same time, it can be hard to be compassionate when faced with someone whose prioritising of alcohol can lead to seemingly selfish behaviour. At times like this, I try to keep in mind the other people affected by the patient’s addiction. When I see alcoholics who are parents of young children, I feel a particular sense of urgency to get them the help that they need in the hope that they can then be fully present as parents. Many of the adults I see with mental health problems were once children of alcoholics and it’s clear how damaging that degree of childhood adversity can be. Helping an alcoholic into recovery saves more than just the individual – the ripples are felt far and wide.
Which brings us back to the problem of drug and alcohol services’ inability to respond to the sheer volume of demand. Sadly, there are no easy solutions. There simply isn’t enough money in the NHS pot to do everything we want to do for the health of our population. I don’t envy those who have to decide between spending money on childhood cancer, dementia or addiction services.
All I can tell you is, when you’re sitting opposite someone who is desperate and you know that the necessary treatment exists, but it’s not available, it feels infuriating, embarrassing and heartbreaking all at once. I apologise to such patients and their families for not being able to do more, and tell them how to make a complaint about their care and contact their MP. But these patients don’t want to complain or lobby, they just want help.