- Correspondence to: A Raby
- Accepted 1 February 2011
My wife was shattered and our marriage was nearly shattered, not by my drinking but by the deceit in which I had wrapped it. I am 78. All my adult life I have drunk alcohol, heavily, increasingly. Some years after retirement in 1995, to conceal my drinking I started on vodka. My day became triangulated around alcohol: are the pubs open, does this shop sell half-bottles, dare I ask for another Scotch?
Too often, my wife came home to find me incapable. Once, not understanding, and fearing that I had had a stroke, she took me to the emergency department, and once she called an ambulance. She felt humiliated by the pity the staff showed her and their contempt for me. A crisis erupted around Christmas 2009 when she noticed how frequently I was making large cash withdrawals. I had to tell the truth.
Addiction is selfishness. Having been afraid of the effect on me if my wife found out about my drinking, I had never imagined the devastating effects on her. Suddenly, I seemed to her a fraud. She shrank from family and friends. She developed shingles. She is diabetic: her blood sugar went haywire. Her unhappiness and confusion were palpable. She stated that she could not bear another drunken spell but would leave, and she told our children (each of us had been widowed previously).
At our wedding, her eldest son had expressed gladness that she had found me to look after her. I had not done so. I had devastated her. Nevertheless, he and his siblings were far more supportive than I deserved. My sons were distressed but loving. One of them asked simply, “Which is more important to you, to have another drink or to keep your marriage?”
We have two old friends, a couple, who have been suffering grave health problems. My wife said, “She has coped better than I have.” They could each count on the other, whereas my wife could not count on me—I was the problem.
Our general practitioner, Dr Raby, had introduced me to the classic alcohol regime—“maximum four units a day, two dry days a week.” I promised to follow this, but a unit became a glass, the glass a tumbler . . . five seems little more than four, six than five . . . today without became tomorrow without . . . and back to where we started. I went to see him again with my wife. She poured out the whole story and he promised to arrange the help I needed.
The NHS was excellent, the staff thoughtful, and the approach well structured. Dr Raby introduced me to a friendly and positive specialist nurse. Her advice was categorical. I must give up alcohol completely for at least six months. Addicts give up often but, at least for my type, there comes a truly decisive moment. A concatenation of old reasons for giving up comes together with a powerful new element. Suddenly, deep inside, the option of not giving up closes.
Years earlier, when I gave up smoking, this new element was observing my father die of emphysema. Now, it was my desperate wish to repair the damage to my wife and to save our marriage.
I saw my specialist nurse every couple of weeks. She encouraged me to foresee occasions when I would want a drink and to work out how to handle them, perhaps by circumventing the situation or finding distraction. Above all, she taught me to prepare mentally so that temptation never took hold.
My wife cut her finger on a broken mug and had to be rushed to the emergency department with septicaemia. They operated on her twice and kept her in for a week. She was on antibiotics for a fortnight after she came out. Her resilience had been badly affected by the shock of discovering my addiction, and for months she remained prone to bouts of exhaustion. The only good thing was that the advice I had received from my specialist nurse paid off. I was worried, and most evenings tired and alone, just right for a quick drink. In fact, I barely thought about alcohol.
My track record gave my wife good reason to doubt me. However, she rejected breathalysers and warily took me on trust. My expenditure, blood pressure, and weight fell sharply. I guess my comportment gradually improved from when I had been drinking.
At social events I would state that I was taking a holiday from booze. Some probably muttered, “Aha, I thought he was an alcoholic,” but most, no doubt, had their own concerns and barely noticed. Our children felt that nobody should drink in my presence. They took some convincing that I did not want them penalised by my misbehaviour.
My specialist nurse referred me to a psychiatrist. He carried out a cognitive intelligence test, although I did not realise that’s what it was. Presumably he also evaluated whether I needed chemical help or had yet done myself serious physical or mental damage. Undeservedly, I seemed not to have. He urged me to see a psychologist. I did not want anybody fossicking about in my psyche (there is nothing to find), but I did want to convince my wife that I was tackling things seriously, so I accepted.
The psychologist was easy to talk to and always constructive. She said to me, “Tell your wife that you are the same chap but that the alcohol takes over.” The structure of my eight sessions with her was largely based on research. She wondered why I drank—for example, was it to overcome insecurity or improve my chances sexually? The answer was always “No.”
We discussed the meaning of the word “craving.” To me, craving is sharp, physical yearning, hard to resist. I still feel a craving for tobacco, decades after giving up, if somebody lights up nearby. I have never felt it for alcohol. To the psychologist, craving is merely a wish for something.
She remarked, “There is still a piece of the jigsaw missing.” I do not feel any craving for alcohol, so why did I become alcoholic? I regard myself as intelligent and honest. Nevertheless, for decades I drank to an extent that was downright stupid, and that led to downright dishonesty.
Although every drunkard has something in common with every other drunkard, not all drunkards are the same. We are not all “fighting our demons.” I have no demons. Although uncomfortable and ashamed when hung over, I am otherwise quite at ease with myself. I suffered no secret childhood harm. I loved and respected my parents and cherish their memory. Admittedly, I went to boarding school, but in war time this seemed normal.
I associate alcohol with freedom and manliness, perhaps thanks to the fictional heroes of my adolescence—Bulldog Drummond’s pints, James Bond’s martinis—but mostly I drank because I enjoy the taste and effect. However, alcohol rots your judgment—“one more won’t hurt.” The first “one more” may not. Later comes the one that does—and you are gone.
Once you acknowledge and then understand the problem, you can control it. I left it late. Happily, my wife had the generosity to trust me once more and the persistence to stay with me.
My six months’ abstinence would have ended in mid-July 2010. We were in France, out of range of Dr Raby’s support system, and my wife feared moderation would be impossible. I extended the abstinence period until our return home in September and then for a further few weeks because of another trip abroad.
In October 2010, after nine months’ abstinence, I started drinking occasionally. For me the rule “maximum four units a day, two dry days a week” feels wrong—a maximum easily becomes a norm. Rather than be a steady drinker who takes a regular break, I prefer to be a steady non-drinker who takes the odd glass. It seems to be working.
A doctor’s perspective
Health problems caused by alcohol use are becoming increasingly common as a result of changing patterns of alcohol consumption. One recent report by the National Audit Office estimates that more than 10 million people in the United Kingdom drink consistently more than the amount recommended by the Department of Health.1 This correlates with a doubling in the number of deaths related to alcohol use during the 15 years up to 2006.1 Practitioners in all fields of medicine therefore need to be able to detect problematic patterns of drinking and intervene to prevent the harms that may result from them.
Detecting the problem
As a profession the evidence suggests that generally we are not effective at detecting or managing patients with alcohol problems. Data on practice populations from the NHS Information Centre for 2009 combined with estimates of drinking prevalence from the National Audit Office 20081 suggest that a general practitioner with an average list size of 2000 in England can expect to have around 230 registered men and 160 women who drink excessively. However, a survey of general practitioners in England found that two thirds reported managing only one to six such patients a year.2 Common reasons for not screening for alcohol may include feelings of being inadequately trained, fear of upsetting patients, and the belief that interventions are unlikely to be effective.
Several screening tools are available, such as the AUDIT (PC) (www.alcohollearningcentre.org.uk/_library/AUDIT-PC.doc), which takes about two minutes to complete. It requires little training and can be carried out by a nurse or a healthcare assistant. Screening can be conducted at the initial contact with a patient such as at registration at a general practice. Clinicians should also screen opportunistically when a patient presents with a problem to which alcohol could be a contributory factor (such as discovery of abnormal liver function, or hypertension). In the case of the patient in this article, his presentation with falls was directly related to his use of alcohol and offered an opportunity to inquire about alcohol.
The evidence suggests that even brief interventions (taking as little as 10 minutes to complete) may be effective in reducing the overall level of alcohol use, changing drinking patterns, preventing future drinking problems, improving health, and reducing health care costs. Several tools are readily available, such as through the screening and intervention programme for sensible drinking (SIPS) (see resources box). Such tools help clinicians to structure feedback about alcohol use and to develop treatment goals with the patient. Critical to the success in helping patients is the ability to call on the expertise of other health professionals, in this case an experienced specialist nurse and an extended team.
One of the most important lessons that I have learnt from this and other cases is the need to adopt a non-judgmental approach where the plan is tailored to the needs and goals of the individual patient. There is no “one size fits all” approach. Some people may just need simple advice about how to keep drinking within sensible limits; for others, abstinence may be the only option. In the case of my patient a period of abstinence with a return to controlled drinking has proved effective. As with all patients, however, his journey continues with follow-up and support.
Adrian M Raby, general practitioner
Patterns of problem alcohol use
Hazardous alcohol use—Drinking above the Department of Health’s recommended level with no current evidence of physical, psychological, or social harm (estimated 18% of the population in England)
Harmful alcohol use—Drinking at a level that is already causing harm (7% of the population in England)
Alcohol dependence—A cluster of symptoms including a subjective compulsion to drink, physical withdrawal symptoms, and continued drinking despite evidence of harm
Screening and Intervention Programme for Sensible Drinking, SIPS (www.sips.iop.kcl.ac.uk)—Supports the National Alcohol Harm Reduction Strategy for England; screening and intervention tools are available on the website
Drinkaware (www.drinkaware.co.uk)—Aims to “increase awareness and understanding of the role of alcohol in society” through “campaigning, educational, and partnership work.” The website has advice for drinkers
NHS Choices: Drinking and Alcohol (www.nhs.uk/Livewell/alcohol)—NHS website giving advice for drinkers
Cite this as: BMJ 2011;342:d956
This is one of a series of occasional articles by patients about their experiences that offer lessons to doctors. The BMJ welcomes contributions to the series. Please contact Peter Lapsley () for guidance.
Competing interests: A Raby has completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; not externally peer reviewed.