Case Scenario

I have a patient in her 50s with a history of alcohol abuse. My first contact with this patient was five years ago, during my residency. At that time, she was diagnosed with bleeding esophageal varices secondary to alcohol abuse. She subsequently quit drinking and remained sober and active in her church. However, about one year ago, when her husband became ill, she began drinking again. Since her husband's death three months ago, she has increased her drinking even more, having alcohol first thing in the morning and sometimes coming to my office with alcohol on her breath.

I confronted her about this during several office visits, but each time she denied drinking. At one such visit, I checked her blood alcohol level, which clearly indicated that she hadn't told me the truth.

I have tried to contact her son, with whom she lives, by leaving a message on their telephone answering machine, but there has been no response. What more can I do?

Commentary

There is no harder task than trying to help a patient who denies having a problem. Self-delusion and denial are key elements of alcoholism. Alcoholics may delude themselves into thinking that they are not drinking too much or that they can control their drinking. They may feel a sense of normalcy only when they are drinking, and may believe that they need alcohol in order to cope with the stresses of life. The thought of not being able to take comfort in a drink whenever they feel the need to can be frightening. They may consider alcohol to be their best friend and the focus of their life.

Stopping long-term, regular, heavy drinking requires a major life change, and the difficulty of doing this should never be underestimated. The first step in the healing process for these patients is to admit that they are alcoholic and that they have a drinking problem. The second step is to truly want to stop drinking. The third step is to accept the fact that they must never drink again. For most people, the next step is to admit that they need help to stop drinking and maintain abstinence. It is important to note that there is no such thing as a “cured” alcoholic. Alcoholism is a chronic disease that can go into remission, sometimes indefinitely, but relapse can be provoked by many life situations, both good and bad.

Although the unfortunate woman in this case scenario is heading rapidly toward self-destruction, at this point she may not care. The fact that she had bleeding esophageal varices five years ago indicates that she had been drinking heavily for many years, yet she managed to maintain abstinence for four years after her medical emergency. She has, therefore, already confronted her abuse of alcohol; at least, she must have accepted the fact that drinking was harming her health, even if she did not accept that she was an alcoholic. However, she is now denying evidence that she has resumed heavy drinking, indicating that she does not want to confront the issue at this time, perhaps not even with herself.

It is likely that the stress of her husband's nine-month terminal illness caused her to fall back into heavy drinking. It is only three months since his death, and she is probably using alcohol to numb her grief. It is also possible that she may feel humiliated and ashamed that her excessive drinking is apparent to others, and she just wants to avoid the issue entirely.

There are two positive factors in this scenario: that she managed once to quit drinking for several years and that she continues to visit her physician on a regular basis. I would suggest that it would be counterproductive at this time to confront her about her drinking. It would be unfortunate to drive her away from medical contact and lose her trust. Instead, the focus should be on her grief and how she is coping with the loss of her husband. Bereavement counseling should be offered.

If she accepts bereavement counseling, the concept of heavy drinking as an inappropriate coping mechanism could be gently introduced and explored over time. In addition, the physician could let her know that he or she is aware of the patient's vulnerability to drinking and give her the phone numbers of the local Alcoholics Anonymous (AA) and Women for Sobriety groups.^1,2

It may be difficult for this patient to initiate a phone call to such a group at this stage. If the physician knows of a sympathetic, recovering (preferably female) alcoholic who would be willing to meet with the patient and offer her support, he or she might offer a suggestion such as, “I know someone with a similar situation and background as yours. Would you mind if I asked her to call you?”

Although it is tempting to enlist others to encourage this patient to stop drinking, great care has to be taken not to disclose her medical problems without her consent, not only for medicolegal reasons, but also to retain her trust. Leaving a voice-mail message for her son at home, where she would be likely to hear it, could undermine these goals.

If the patient does decide to seek help, certain facts will help the physician assess the form of treatment and the prognosis for this patient. For example, although she smells of alcohol in the mornings, is she otherwise taking care of herself with respect to nutrition, hygiene, and appearance? How did she quit drinking five years ago, and how did she maintain abstinence for several years? What was her social support system then? If her husband was her main emotional support, recovery now will be more difficult. How supportive is her son? Does he abuse alcohol too? Was her church an important source of support, and is she still an active member?

If this patient does seek help for her drinking problem, it is likely that she will need inpatient detoxification, partly because she may be in danger of severe withdrawal if she stops drinking suddenly and partly because she may no longer have a supportive family or social network.^3–5 She is likely to benefit from training in coping skills to prevent relapse and would probably benefit from participation in self-help support groups such as AA and Women for Sobriety.^1,2,3,6

If the patient refuses alcohol counseling and advice when it is offered, the physician faces the frustrating necessity of waiting, while presenting a receptive, nonjudgmental, encouraging, and sympathetic front at each office visit, until the patient is ready to seek help. It may well be that help will not be sought until more physical complications develop.