“I want to quit drinking, but it calms me down. Sometimes I drink to numb the pain in my shoulder — old football injury,” my patient John said to me in the hospital last week. “Same with the smoking. It keeps me calm and I don’t think I’ll ever quit smoking. It’s just a part of who I am.”
John recently moved to Florida but detailed for me his numerous hospitalizations for alcohol-related issues in Tennessee. Another alcoholic, I said to myself, mentally reviewing list of my patients in the same boat. John isn’t ready to quit, or even in what we’d call the pre-contemplation stage of change. Nothing I can do for him, I thought as I walked out the door.
Smoker. Drunk. Drug addict. Fat person.
The blame game is so easy to slip into. With each label, we impose order on an otherwise disorderly system of life, reassuring ourselves that it will never happen to us.
When contemplating illness, we want to believe that there is a system, a reason behind the woe. Now that science is the new religion, we want to frame the frightening prospects of illness within tight borders. If we can come up with a reason for a malady, order emerges from the disorder. Where our ancestors might have looked to the alignment of stars for the answer, we seek solace in molecular biology. She died of lung cancer, but she smoked, so, you know.
In rationalizing away our own collective mortality, however, we create a dichotomy that often blames the victim: Alcoholics are supposed to die of cirrhosis and smokers of lung cancer. They did this to themselves, we callously say. We all have free will and choose our own path.
At any given time, three-quarters of my patients in Florida are in the hospital for reasons connected to lifestyle. As a doctor, I’m relatively helpless. I give medicines to open up lungs damaged by smoking or to stave off potentially deadly alcohol withdrawal. I know that the majority of the alcoholics I treat will start drinking within days, if not hours, of their discharge. The smokers likely won’t even make it to the parking garage before lighting up.
Ironically, doctors and hospitals have labeled some dangerous behaviors more off-limits than others. While alcoholics used to be permitted access to alcohol in hospitals in order to treat their other illnesses, this is now prohibited (except in the Veterans Administration hospital system, where Milwaukee’s Best is still on formulary). Smoking is prohibited by patients and staff anywhere on hospital property. Many hospitals enforce the rule so strictly that a patient must leave the hospital AMA (against medical advice) in order to take a few puffs.
These same hospitals, however, offer full-calorie soda and sodium-encrusted chips at vending machines just outside intensive care units where patients are receiving care for critical conditions related to obesity and high blood pressure. Many large academic hospitals also have more than one fast food restaurant in the lobby as well.
Blaming the victim neglects the challenging reality of the situation. The biochemical pathways of addiction — whether to tobacco, alcohol, drugs, or food — are all the same. Patients do not make these choices with pure freedom, but are driven by their own neurotransmitters.
Genetics may contribute as much as 50 percent to addictions. Environment may do more than shape the psyche of an individual but may in fact alter one’s genetics over time, reprogramming their DNA to behave in patterns that lead to disease. Even if we minimize the role biology plays in addiction, social issues are inextricably tangled with disease. Poverty and lack of education play a grim role: 3.7 million Americans living in poverty require drug or alcohol treatment, but less than a quarter of those actually receive the treatment they need, according to the U.S. Census Bureau.
Perhaps we need to re-examine the conditions that lead to the high prevalence of these diseases in American society. Up to ten percent of all Americans are dependent upon alcohol, over one-third of adults are obese, and more than one in five consume tobacco products. Smoking and obesity combined contribute to 40 percent of all deaths in the United States and yet are stigmatized significantly less than alcohol and drug dependence. While only seven percent of deaths are attributable to alcohol and illicit drug use, they do still cost the U.S. economy $223 billion and $193 billion, respectively, largely due to lost workplace productivity.
Later that day, John’s blood test results showed he had hepatitis C, contracted through some direct exchange of bodily fluid, whether sexual or through a common cocaine straw. When I asked him what he knew about hepatitis C, he mentioned that his sister also has the disease, contracted from IV drug abuse.
“With your hepatitis C and drinking, you have a high likelihood of developing cirrhosis. Have you heard of cirrhosis, or scarring of the liver?” I asked.
“I know what cirrhosis is. My daddy has it. I don’t want that,” John replied, his voice trailing off.
John’s family is a classic example where genetics, poverty, and environment contributed to at least three members of his immediate family becoming addicts and smokers. Instead of passing judgement, we must provide support — medical, psychological and social. Not only will we save our healthcare dollars, we’ll help our human family members back on their feet.
Vincent DeGennaro is an internal medicine doctor and global public health specialist in the University of Florida’s Division of Infectious Diseases and Global Medicine and works half time in Haiti with the nonprofit Project Medishare. See his An American Doctor in Haiti blog.