‘I Want To Stop Drinking Alcohol NOW But I Can’t’: Alcohol Abuse and Alcoholism

‘I Want To Stop Drinking Alcohol But I Can’t’: Alcohol Abuse and Alcoholism

By Dr. Natan Schleider, M.D.

July 29th, 2017

‘I need you over here quick doc, I want to stop drinking alcohol NOW but I can’t.’

Among the most common house call requests I get is from the loved one or family member of an alcoholic–and sometimes the patient themselves–who needs to quickly sober up. While the drinking has been heavy for years, a situation has presented itself where the patient is ready and willing to stop drinking alcohol but cannot.

Why after years of drinking is the patient asking for treatment so quickly?

The answer is simple: fear of going into alcohol withdrawal. This is the fancy medical terms for signs and symptoms related to cessation or reduction in use of drinking alcohol after heavy use characterized by sweating and high heart rate, hand tremors, insomnia, nausea or vomiting, anxiety, and, when things get bad auditory and visual hallucinations and seizures.

Of note, you may have heard the term delirium tremens or ‘DTs.’ This is somewhat synonymous with the later stages of alcohol withdrawal, normally occurring days 3-5 after the alcoholic has stopped drinking.  Imagine not sleeping for 3-5 days and being deprived of your alcoholic elixir. Mix in some nausea, vomiting, and dehydration. I give you the perfect cocktail for psychosis ready to happen, meaning the alcoholic will literally begin to hear and see things, act nuts, and start shaking or trembling–hence the term delirium tremens.

Now since alcohol withdrawal happens within hours for most alcoholics, time is of the essence to treat the patient or risk of relapse to drinking alcohol is high. In fact, even with treatment and appropriate alcohol detoxification, the sad truth is, the majority of alcoholics with less than one year sober will return to drinking alcohol, regardless or the medical treatments, twelve step programs, and other resources available.

That said, even the longest road toward recovery and long term sobriety begins with a single step. That First Step of Alcoholics Anonymous (AA) is “We admitted we were powerless over alcohol–that our lives had become unmanageable.” Being an addiction medicine doctor, I am a big advocate of 12 step programs like AA. The ‘Big Book’ of Alcoholics Anonymous has a lot of good stuff and even if you don’t believe in all that God-Stuff, it is full of information that is relevant in 2017, despite the fact that it was written in 1939.  Another fundamental point made on p.30 4th edition of the Big Book is “We learned that we had to fully concede to our innermost selves that we were alcoholics. This is the first step in recovery.” I n my experience, those patients who readily admit that they are alcoholics and say they are alcoholics have a higher chance of recovery than those who have called me just to sober up for a while so they can drink like a gentleman or a lady. As they say in AA, ‘once a pickle, never a cucumber.’  That is, once your drinking of alcohol has spiraled out of control, the chance of returning to normal drinking is extremely low.

While advocating for AA, from a medical and practical standpoint, small chance that an alcoholic who is trembling and vomiting in alcohol withdrawal will delve straight into any sort of non-medical treatment program or 12 step program like AA until their alcohol withdrawal has been safely treated.

So what to do if you can’t stop drinking, the craving are bad, and as soon as you try to stop on your own, you start feeling anxious, shaky, sweaty, and crave alcohol?

Good question. The answer is alcohol detoxification also called alcohol detox or just detox. I often get asked for intravenous (IV) fluids to rid the patients body of all the evil chemicals that have accumulated from heavy drinking of alcohol. While it is true that heavy alcohol abuse can damage the liver and cause certain compounds in the blood to accumulate which we find on blood tests like elevated liver functions tests (LFTs) or elevated bilirubin, the value of IV fluids is highest if the patient is dehydrated and/or cannot eat or drink. While I am a spiritual doctor and do believe in God, I do not know of any evil spirits or toxins that accumulate as a result of drinking alcohol. So to eliminate the confusion, when we detox a patient, alcohol is the actual toxin–or poison so to speak–that the addiction doctor is addressing and treating.

Now I suppose the hardcore alcoholics have succeed in locking themselves in a room or being chained to a bed. Others may have found success going to some ‘dry’ region and I’m not talking the desert. I mean going or flying somewhere where alcohol does not exist–yes there are such place, even counties and towns in the USA in which  it is illegal to buy and sell alcohol dating back from prohibition-era America.

If you are trying an at home detox without help and hunted around on the internet for home  remedies, you have probably read that you should taper down you alcohol use, perhaps by using beer in lesser amounts. While I should admonish you as a physician, let’s be real. Addiction medicine doctors use tapers all the time to wean patients off other habit forming drugs and substances of abuse. While I do not condone this, if you are going to do this on your own, I would take a multivitamin, Vitamin B Complex, and Thiamine (which is Vitamin B1). Do your best to stay hydrated, eat nutritious foods, and go to an AA meeting as soon as possible.

If you are seeking medical help, what to expect? Well, the mainstay of therapy for treatment of alcohol withdrawal are the benzodiazepenes (the family of Valium medicines also called ‘benzos’). That’s right, addiction medicine doctors substitute one habit forming medicine for another. Unfortunately, these are the best tool in out tool box and they work.

While many benzodiazepene exist, chlordiazapoxide (Librium) is FDA approved for treatment of alcohol withdrawal. Lorazepam (Ativan) is one of my favorites to use as well. Why? Both are short-acting and allow flexibility of dosing. Sometimes I need to improvise if the patient is vomiting and cannot swallow pills in which case some orally dissolving formulation of clonazepam and alprazolam are available.

Remember that the most serious symptoms of alcohol withdrawal like seizures (and death can occur as a result) occur at days 3 to 5 typically so the treatment course needs to last a good week or so before the patient is physically in the clear, in general. One must consider variables as to how long and how heavily and how much the patient was drinking but this is general consensus.

Time for me to wrap up my blog for now as I have to give my 4 year old daughter breakfast but I wanted to add an important note on alcoholism. There is a lot of press about the opiod epidemic in recent years but let’s realize the current statistics:  an estimated 88,000 American died in 2015 as a result of alcohol related deaths [Source: National Institute on Alcohol Abuse and Alcoholism https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics] while the 33,000 Americans died from opiod related deaths in 2015 [Source: Center for Disease Control and Prevention https://www.cdc.gov/drugoverdose/index.html].  I’m not trying to diminish the opiod epidemic as deaths are rising at an alarming rate and I will likely be writing about this in the future; however, I did want to emphasize the toll that alcohol continues to take and even though alcohol kills more Americans by a rate of nearly three to one, our treatment goals need not be focused nor eclipsed by the current opiod epidemic. Let’s keep a view of the big picture people.

Thanks for reading and comments welcome.

Diary of a Insomniac Physician aka What to Do If You Can’t Sleep and Suffer Insomnia: Part 2

Diary of a Insomniac Physician aka What to Do If You Can’t Sleep and Suffer Insomnia: Part 2

By Dr. Natan Schleider, M.D.

July 17th, 2017 3:49 AM

Can’t sleep? Join the club. 5.5 million Americans visit their doctor every year for treatment of insomnia and I’m one of them.

Having tried proper sleep hygiene techniques discussed in my blog post yesterday, I visited the drug store.

Sleepy time tea was tried. No effect. Melatonin 1 mg was tried. Nothing. Incidentally, melatonin generally needs to be taken nightly and with regularity to take effect. I increased the dose to 3 mg nightly. No effect. Then 10 mg. Still I tossed and turned.

Next I tried some sedating anti-histamines for my trouble sleeping, namely diphenhydramine better known as Benadryl. This usually comes as 25 mg tablets or capsules at the pharmacy and it is approved by the Food and Drug Administration for short-term treatment of insomnia at doses up to 50 mg nightly taken 30 minutes before bed. [I have some patients that swear by Zzzquil which is actually just diphenhydramine as well].

So how did the diphenhydramine (Benadryl) work? Not at all for me. It made me groggy (and did help my allergies) but did not put me to sleep. Some of my patients find this stuff as sedating as a horse tranquilizer but not me.

Ultimately I went to my doctor where a medley of prescription medicines were tried. He finally pointed out that what was keeping me awake was my increased stress of being on call and the fact that my cell phone my ring at any time in the middle of the night.

So I decided to change the nature of my medical practice and unless I had a patient in the hospital or had a particular patient I was worried about, I now turn my cell phone to silent most nights so I can sleep. This has helped more than all the pills; however, for the sake of thoroughness let’s go over some of my preferred medicines for treating insomnia.

Below is a list of Dr. Natan Schleider’s prescription medicines to consider when you cannot sleep:

  1. If you have trouble falling asleep, controlled release melatonin or Ramelteon. These are not habit forming so they are a good place to start. If these do not work, there are a family of medicines called “Z-drugs.” These are drugs like Ambien and Lunesta and are habit forming. Being an addiction medicine doctor, I caution against these. If you can take them sparingly, that is, one or two nights weekly, your chances of becoming dependent are lower but not impossible. Unlike the melatonin and Ramelteon, the immedate release forms of Z-drugs can be taken IF needed while the melatonin analogs must be taken nightly.
  2. If you have the type of insomnia where you cannot stay asleep consider doxepin (Silenor), an ‘oldy but goody’ in the family of tricyclic antidepressants also FDA approved for insomnia. This is also a nice option if you are diagnosed with depression.
  3. Suvorexant (Belsomra) is a reatively new medicine for treating insomnia which I have zero experience with but for the sake of being thorough I am including this in the list. It is FDA approved for treating insomnia but is a controlled medicine meaning it is habit forming so caution with use. On a personal note I tend not to prescribe the newest medicine to hit the market. A lot of new medicines are recalled like Bextra and Vioxx, rememebr those? Better to go with medicines with a good safety profile in my opinion.
  4. The following medicines are commonly prescribed by psychiatrists for insomnia (and even by me once in a while) although admittedly, the evidence for them is lacking but my patients say they work: trazodone and Seroquel.

Well, there are a lot more medicines out there that are sedating and I’m no sleep specialist, just an insomnia specialist. I’m gonna try to get an hour of sleep before getting my daughter ready for school. Over and out.

Diary of a Insomniac Physician aka What to Do If You Can’t Sleep and You Suffer Insomnia: Part 1

Diary of a Insomniac Physician aka What to Do If You Can’t Sleep and You Suffer Insomnia: Part 1

By Dr. Natan Schleider, M.D.

July 16th, 2017

It is 2:08 am on Sunday July 16th, 2017 and for no particular reason, I cannot sleep. I did not drink any caffeine today. I am practicing good ‘sleep hygiene’ [we will get to that later but that is the fancy doctor jargon meaning all the stuff you are supposed to do when you sleep, for example, go to bed at the same time every night).

This month’s journal of the American Academy of Family Physicians, American Family Physician (Volume 96 Number 1, July 1st, 2017 p.29-35) has an article which I read: ‘Insomnia: Pharmacologic Therapy.’

Given that my 4 year old daughter, Ellie, keeps kicking me in the head as she tosses and turns at night in my bed (and refuses to use her toddler bed), I thought I would add my personal knowledge and experience with insomnia. Ok, now I realize I am not practicing proper sleep hygiene but kicking your toddler to the curb so you can sleep simply is not in the medical textbooks (and you parents out there can now say ‘I told you so’ and warn me of the dangers of letting children sleep in your bed but Ellie says “Daddy I’m afraid of monsters in the dark and want to sleep in your bed.” Yet I digress.)

So who is more likely to suffer insomnia?

  1. Women get it twice as often as men, especially if pregnant or post menopausal
  2. Older adults
  3. Patients with chronic medical conditions like heart and lung disease and psychiatric conditions like depression, anxiety, substance abuse, and posttraumatic stress disorder.
  4. People who are grieving death of a loved one
  5. People separating or divorcing
  6. People of lower socioeconomic class
  7. Patients withdrawing for alcohol and opiates

As a family physician and addiction medicine doctor, I see a lot of patients for insomnia, I mean, it is up there for the primary purpose of the visit with high blood pressure and sore throat.

Having been on call for a medical practice where patients and the hospital can call at all hours of the night, my insomnia has worsened over the years. Maybe I am becoming one of those ‘older adults’ that gets less sleep? Maybe now that I’m a single parent I ‘sleep with one eye open’ which, as most single parents will attest to, means we don’t get much sleep?

Here are Dr. Schleider’s sleep hygiene techniques or ‘behavioral interventions’ as the journal article liked to put it that I use to try to get to sleep. These work most nights:

  1. I go to bed around 8pm every night with my daughter, even on Saturday and Sunday (yes, I’m boring but I value my sleep).  I wake up around 3am to 4am every morning. A regular sleep schedule gets you body used to falling asleep on time.
  2. Caffeine is a luxury item I cannot afford and I drink coffee or tea or diet coke maybe twice a week and only in the morning.
  3. The human body likes a cool, quiet, dark place to sleep so keep the lights out and the room chilly. I use a face mask and ear plugs and white noise from a fan and an air conditioner in summertime for the double bonus of keeping me cool and the ambient white noise.
  4. Avoid naps which can mess with my sleep cycle.
  5. I am not supposed to read or watch TV in bed according to the American Sleep Association but here I am guilty by proxy, that is, Ellie makes me watch My Little Pony with her as her ‘white noise’ is the television which she needs to fall asleep. This is a real problem for me…
  6. I do not drink alcohol or smoke tobacco or drink any energy drinks as these interfere with sleep.
  7. I try to exercise before 12 noon. Exercising before going to sleep, while better than no exercise at all, can release neurotransmitters and hormones (IE endorphins and adrenaline) which can keep you awake. The verdict is out in my mind on vigorous sexual activity before bed but my advice is: go for it,  enjoy it while it lasts unless it really affects you sleep cycle in which case maybe you and your partner can switch to morning intercourse.
  8. I try to keep busy until I am so tired, I fall asleep. This is contrary to other advice which suggests mediation and baths and scented candles before bed but that just doesn’t work for me.

Well, that’s pretty much it on ways to get to sleep without medicines or supplements, at least in my personal and professional experience. Please add any comments or suggestions you have as it is almost 3am here in New York City and I should try to get back to bed!

 

 

Why Pay Money For a House Call Doctor?

With an urgent care center on every corner and ‘telemedicine’ (that is the fancy word for being able to consult a doctor, nurse, or physician assistant via your smart phone or your computer), this begs the question:

Why Pay Good Money For a House Call Doctor?

1. You are home bound, really sick, and do not want to go to the emergency room. This is one of the most common house call requests I get. A good house call doctor can do all the triage testing that is done in an emergency room like vital signs, an EKG, cardiac enzymes, x-rays, urine,  blood tests, ultrasounds, etc…all in your home. The emergency room would charge thousands of dollars for this testing. Why not have this done in your home and get it reimbursed by your insurance plan?

2. You need a narcotic medication like a pain killer or a benzodiazapene (that is the pharmaceutical term for a medicine in the Valium family like alprazolam aka Xanax). These cannot be prescribed over the phone or by any of those telemedicine companies.

3. You want quality medical care by a Board Certified Medical Doctor. I am sure there are plenty of very nice nurses and physician assistants out there, but if I am really sick or my family is really sick, I want a competent, experienced physician caring for them.

4. You do not want to contract a bunch of germs in a doctor’s office or hospital. Do you know what a nosocomial infection is? Well there are medical journals dedicated to the word ‘nosocomial.” It is the fancy word for hospital-acquired infection. Hospitals and busy doctors offices are the play grounds of nasty bacteria. I don’t care how much antibacterial hand sanitizer is hanging around. [In fact, the hand sanitizers may be predisposing to resistant bacteria but that is another topic].

5. You are busy working and the cost of getting to a doctor, waiting around, seeing the doctor, and returning to work out weighs the cost of the doctor coming to you. Let’s face it, here in Manhattan, my time is money. When I am busy seeing patients in the office, do I call a house call doctor for myself or my daughter when busy? You bet!

“I’m Going to a Developing Country for Vacation, Do I Really Need Travel Vaccines? I Was There Before and I Was Fine.”

“I’m Going to a Developing Country for Vacation, Do I Really Need Any Travel Vaccines? I Was There Before and I Was Fine.”

By Natan Schleider, M.D.

July 2nd, 2017

I get the above question quite often from my patients, often days before they are leaving for Thailand, India, South America, Africa..my patients are world travelers.

Usually the question is followed by a statement like: “I only drink bottled water and will only be in the jungle for a few days.”

The answer to the question is a definitive YES.  Unless of course you like having Typhoid’s bloody diarrhea, Yellow Fever, or Malaria. Sure they may kill you but it will make a hell of a cocktail story 6-12 weeks after your hospitalization. Not to mention you may even get a few people saying: ‘You simply must share your weight loss secrets! You must have dropped 100 pounds darling!”

The Center of Disease Control (www.cdc.gov) has very specific guidelines in the Traveler’s Health section, just chose your destination and figure out what vaccines you need and what medicines you may need (for example Malaria prevention, antibiotics, sunblock, mosquito nets) (https://wwwnc.cdc.gov/travel/destinations/list/)

And I have followed them all! I have literally had every vaccine out there, including Rabies! That’s right! I was bitten by a dog when I was in medical school in Israel and had to have four intramuscular shots (they are not given into the stomach, that is a myth, they are given into the shoulder like a flu shot) weekly for 4 consecutive weeks.

One issue is Travel Vaccines are not covered by most health insurance plans and are not cheap. BUT, they are a lot less expensive than the cost of a private jet flying you to a reputable hospital, that is for sure.

Remember to get the vaccines at least 10 to 14 days BEFORE you leave for your trip to allow your body to build protective antibodies.

You may need a Yellow Vaccine Card if you are getting the Yellow Fever Vaccine (this is almost only needed if you are going to certain regions in Africa). I try to give all my patients this card and email my patients a PDF copy in case they lose the card. Ask you Travel Vaccine Doctor for a Yellow Vaccine card even if you are not getting the Yellow Fever Vaccine. Why? It fits nicely in your passport and is a great way to keep track of adult vaccines.

Look, you just booked a ticket to fly hundreds if not thousands of miles for the trip of a lifetime and I am guessing you spent decent money for the trip.

You may be spending most of your time on a resort. But even those ice cubes in the resort’s five star cocktails can carry viruses and bacteria so do yourself a favor and invest some time in your health and vaccinate.

The vaccines will confer immunity for anywhere from two to ten years so think of them as an investment into your health.

Gone are The Days Where to Build a Medical Practice You Just ‘Hang a Shingle’…

Gone are The Days Where to Build a Medical Practice You Just ‘Hang a Shingle’…

By Natan Schleider, M.D.

July 1st, 2017

“Hang a Shingle?!” What are you talking about? Most young readers are probably unfamiliar with this expression.

To “hang a shingle” refers to a time before the internet (yes, the stone ages) where, when starting a medical practice–or any other small professional business for that matter like a law practice–a young doctor hung a sign  with his or her name engraved (often in front of their home office) to attract new patients.

A shingle here refers to a piece of wood I suppose, not to be confused with the painful rash caused by Varicella Zoster virus yet I digress.

Having just put up a newly revised website, apparently my blogs carry more weight with search engines than my board certifications–so says my online marketing campaign adviser.

Is this why I am writing or should I say blogging? Sure in part.

A bunch of other factors such as how often I tweet on twitter.com and how often my patients “like” my practice on various social media outlets will help get my practice’s website, www.doctorinthefamily.com, highly ranked on Google and other search engines when patients are looking for a doctor.

In other words, I could be a Nobel prize winning, cancer-curing, super nice medical doctor but without the social media buzz, my website would not be highly ranked.

Apparently I’m a dinosaur who has stayed away from the social media limelight for far too long.

Adapt or die.

Follow me on facebook and twitter. Oh, I do not have accounts with them set up yet. And writing that is like nails on a chalkboard.

But if everyone else is glued to their smart phones not interacting with the humans around them, walking into telephone poles as their thumbs busily peck away, I should see what all the hype is about, right?