To drink or not to drink (too much)- this is not a question!

Gabriel M. Gurman
Chief Editor
gurman@bgu.ac.il

Many years ago, during my residency in Toronto, I used to work with a very nice and friendly resident, younger than me who,  by coming from an English-speaking country, helped me a lot in my efforts to become accustomed with the work system  (and language!) in that very prestigious Canadian hospital.

But there was a problem. Much too often, and especially during night on calls, he could not be of any help. He was confused, stuttered, could not perform usual manoeuvers or put notes in the patient’s chart. He quit the job after just a couple of months.

This was the first time I met an alcohol-dependent physician.

But alcohol abuse is not a new subject. Alcohol addiction is common all over the world, and naturally it does affect medical personnel, at least as frequently and as severely as the general population.

This social and eventually professional problem is, in general, underestimated since opiates and similar drugs usually take first place on the list of priorities regarding the perennial campaign against drug abuse.

Besides, alcohol use is worldly considered a normal and a social habit, so alcohol abuse is much more difficult to recognise and treat.

This is the reason why most of the specific literature about drug abuse refers only to opiates and related drugs, with few data on exaggerating alcohol use.

It is not the intention of this editorial to review the myriad of clinical problems created by alcohol abuse, or to enumerate the pathophysiological effects of alcohol overuse.

I would just like to bring to the attention of our readers and younger colleagues some aspects of the alcohol abuse and to mention, in short, the steps which are to be taken by peers in the case one of us presents clear signs of this addiction.

Speaking in general about alcohol abuse, there are some data defining it as the seventh leading risk factor for both death and disability-adjusted life years, three times more in men than in women (1).

Alcohol abuse was identified as a comorbidity accompanying depression and other affective disorders (2). Physicians are specifically affected by this, and suicide rate is 2-3 times higher for them than for the general population (3).

Tolerance is more often encountered in alcohol abusers than in drug abusers. It is defined as “the need to absorb continuously increased amounts of alcohol in order to obtain the same desired effect” (4).

There are no specific data about alcohol abuse among anaesthesiologists, but data about drug abuse show that addiction, in general, is a major issue in the anaesthesia workplace (5).

One can easily understand the relatively high prevalence of alcohol abuse among anaesthesiologists. Production pressure and professional stress are factors which importance cannot be overemphasized (5). In spite of the fact that there are not exact data regarding the rate of alcohol abuse among anaesthesiologists, the feeling is that the numbers are higher than for other medical specialties. It seems that a significant portion of drug abusers among anaesthesiologists are addicted to alcohol.

And why?

The worldwide manpower problem creates a situation in which anaesthesiologists are overworked and always under the influence of what I called the WHEN syndrome (weekends, holidays, evenings and nights), with a serious effect of our professional, social and familial life (6) .

Anaesthesia is, among other things, a service profession, which demands the physician to be able to work in a team, and to act accordingly. Frictions between team members are not unusual in the OR, and this atmosphere could lead to tension and conflicts.

But contrary to almost any medical field, the anaesthesiologist is still obliged, in spite of the latest technological innovations (see the increasing use of ultrasound for performing various procedures), to use a lot of “blind” methods in his/her daily practice, sometimes a very frustrating situation.

Anaesthesia complications are not easily accepted, neither by the patient or his/her family, nor by the medical community. Dehiscence of a small bowel anastomose could be much more understandable than an epidural hematoma after a traumatic spinal puncture.

Last but not least, in some countries, the anaesthesiologist competes in his/her daily activity in the operating room with non-medical professions, a situation which augments the feeling of  frustration produced by all the above.

This permanent stress, felt or not, creates the need for relaxation. For some, a couple of free days would “recharge the batteries” and affords the smooth return to work.

Some others find at home and in their social milieu a source of relief, the joy of spending time with close family members and friends, compensating for the heavy work performed during the day.

But many, maybe too many, would find the panacea for their problems in using drugs and/or alcohol.

It usually starts as a nice and not at all dangerous habit. One or two drinks once at home, after a too busy day, two or three drinks during the weekend dinners, this could be the usual scenario for a first step in the direction of alcohol abuse. The way from the status of social drinker, meaning 1-2 drinks that might soften the harsh events of the day or increase sociability level, to alcohol addiction could be a rather short one.

Addiction could be diagnosed by becoming familiar with your peer’s habits: drinking large amounts of alcohol in any occasion, difficulty in cutting down, a permanent and a strong desire for a drink, and mainly the appearance of alcohol tolerance.

This is how the literature defines the heavy drinker: more than five drinks per day, in more than one occasion, and here is the definition of  alcohol addiction:

a chronic, progressive, potentially fatal disorder, marked by excessive and usually compulsive drinking of alcohol leading to psychological and physical dependence.

The consequences are disastrous: depression (one of the factors leading to cardiovascular diseases) family and social dysfunction, decreased productivity, damaged professional relations, failure to complete residency, failure to pass exams, etc.

If so, what can be done in order to manage this rather tragic situation?

I will just mention the need for a permanent education, from childhood to adult life, by not avoiding the subject in every, single targeted conversation, since prevention is the best treatment of any pathological situation.

Identifying the person suffering from alcohol addiction has to be followed by immediate measures, taken in two directions. In those rather “easy” cases, the best thing to do is to try to take care of the factors which produced this permanent stress, by reducing the amount of work and offering assistance in managing difficult cases in the operating room or in the intensive care unit. But sometimes there is a need for professional intervention, and in such a situation professional intervention is highly demanded. Today, chronic alcoholism could be successfully treated, by proposing the patient a list of things to be done in order to completely change his/her habits.

The return to work is problematic. It has to be done under permanent supervision (7), at least at the beginning, by observing and assessing the physician ability to cope with the demands of the routine activity.

Finally, one cannot forget a sentence taken from one of Raymond Chandler’s plays: “a man who drinks too much on occasion is still the same man as he was sober. An alcoholic, a real alcoholic, is not the same man at all. You can’t predict anything about him for sure, except that he will be someone you never met before.”

Each of us can be in the same situation as that poor physician, addicted to the glass full of alcohol, but each of us is supposed to be responsible for helping the others, those addicted and in need of help.

References

1. Hyman SA et al. Anesth Analg 2017;125:2009
2. HawtonK et al. J Epidemiol Community Health 2001;55:296
3. Farrugia J et al. Rev Med Liege 2019;74:336
4. Silverstein JH et al. Anesthesiology 1993;79:354
5. Gurman GM et al. J Clin Monitor Comput 2012;26:329
6. Gurman GM. ESAIC Newsletter nr 61, Autumn 2015
7. Strike PC, Steptoe A Heart 2002;88:441