As a physician in training, I would like to address and delve into the afflictions of a typical chronic alcoholic using the following real patient (for anonymity, I will call him Mr. T). And yes, chronic alcoholism, like any substance abuse disorder, is a mental illness, not a sign of weakness or inherent malevolence on the part of its victim.
This patient, through his chronic alcoholism, which ultimately cost him his job with the local corner store, entered a downward spiral into homelessness, poverty, and severe health complications which ultimately went on to be fatal.
While addressing his alcohol abuse and getting crucial health care in a timely manner would have been essential, his situation deteriorated to the stage where he faced many obstacles to receiving these crucial health interventions.
Firstly, through losing his job and being unemployed for seven years, Mr. T faced severe financial difficulties and would likely not have been able to cover the costs of copayments, hospital and clinic visits, and various prescribed medications for the somatic manifestations of his alcoholism.
In the U.S., even though Medicaid is an option for low-income individuals, its coverage of homeless individuals like Mr. T is erratic at best. Mr. T, without a permanent home address, and likely without the proper identification, communication media, and the mental capacity (likely often being inebriated), would have found even applying for this low-cost option to be difficult.
Moreover, as a chronic alcoholic, Mr. T, having to choose between spending any money he did have on obtaining more alcohol or getting treatment, would likely have opted for the former, thus perpetuating both the financial barrier and the exacerbation of his medical condition.
Stigma From the Health Community
Secondly, Mr. T faced a significant barrier of stigma from the health care community towards both his alcoholism and his homelessness. Many homeless individuals like Mr. T have been on the receiving end of discriminatory, inhospitable treatment by health care providers.
This apparent inhospitality, through words and actions, is perceived by much of the homeless as stemming from negative judgment of their situation, motivated by the widely adopted stereotype linking homelessness with negative traits such as laziness (Hudak et al., 2007).
Mr. T also faced the additional stigma of being an alcoholic. Alcoholics and other substance abuse disorder victims are one of the most highly stigmatized populations. Perceptions of individuals with alcohol disorders tend to be negative labels, such as reckless, immoral, and lacking control (Keyes et al., 2010).
These well-established beliefs would make people like Mr. T less likely to pursue treatment. In retrospect, there were a myriad of different social and community resources that could have been called upon to address his alcohol issues.
One well-established and widely popular resource is Alcoholics Anonymous (AA). This is a mutual aid support group where individuals with alcohol issues convene at regular meetings, where they can share their experiences with one another, while maintaining anonymity and helping one other to overcome their drinking.
There are no stringent requirements, with membership open to anyone looking to address their alcoholism.
Secondly, one resource which could have addressed both Mr. T’s homelessness and alcoholism is that of public supportive housing. While providing a means of food, shelter, and care, supportive housing also provides social services to individuals, often providing alcohol and substance use rehabilitation.
A Number of Treatment Options Available
Additionally, there are a number of inpatient and outpatient treatment and rehabilitation services for alcoholism that could have been called upon. Treatment in an inpatient setting entails entering a residential facility, which may be either affiliated with a larger hospital or simply an independent facility.
Here, Mr. T would have been supervised as he underwent medical detoxification, followed by obtaining the requisite therapy, such as cognitive behavioral therapy, to address the root cause of his alcoholism and help him to cope with and embrace sobriety.
In an outpatient setting, Mr. T would have received similar detoxification and therapy, but would receive less monitoring than in an in-patient setting, where he would have 24/7 supervision. However, with outpatient treatment, there is substantial ‘aftercare’ to aid in re-integration to the community, through support groups in which individuals work together to create a personalized relapse prevention plan to maintain sobriety.
Lastly, many hospitals and even free clinics utilize SBIRT (Screening, Brief Intervention and Referral to Treatment), an approach where patients are screened for having substance abuse disorders or the risk for it.
It consists of a survey asking about drinking habits, building rapport with the patient and allowing them to acknowledge their problem and negotiate a treatment plan.
The approach also involves referring the patient to all the more extensive lines of treatment.
Free clinics that are exponents of SBIRT are yet another resource that could have addressed Mr. T’s alcoholism.
The resources above would all have been effective in addressing Mr. T’s alcoholism, and allowing for early intervention to prevent his health from deteriorating the way it did.
Alcoholics Anonymous would have allowed Mr. T to work with fellow individuals who suffered from alcoholism. Here, he would have been in a support group free of judgment or stigma, and could have learned from his peers, adopting methods that worked for them in overcoming their alcohol issue.
In terms of supportive housing, this resource would not have only provided Mr. T with a roof over his head, but also, an opportunity to receive treatment for his alcoholism, as many of these housing sites have mental health programs and/or are affiliated with various mental health organizations combatting substance abuse.
Inpatient treatment would have been an effective option as it would have provided all the lines of treatment, with detoxification and therapy, all while supervising Mr. T during this difficult time.
Detoxification is the most challenging part of recovery, particularly the unpleasant physiological effects of alcohol cessation. Having someone monitor Mr. T would have better enabled him to cope with this difficult transition.
Outpatient treatment, while not providing the constant monitoring of inpatient treatment, would have provided Mr. T with a greater degree of autonomy during his transition from alcohol, while also providing the requisite means of periodic follow-up during detoxification, therapy, and coping for life after alcohol.
Both the inpatient and outpatient treatment options consist of state-funded forms that address populations with little to no income, so this would overcome the financial barrier that the unemployed Mr. T faced.
Lastly, just during Mr. T’s hospital visits, had SBIRT been conducted, it would have allowed for early detection and timely intervention for chronic alcoholism, allowing patients like Mr. T to acknowledge their problem, learn about lines of treatment, and actively participate and work with their doctors in tailoring a treatment plan to their needs.
This is now done at many hospitals, including where I am based, at the Stony Brook University Hospital, and even at the Stony Brook HOME Free Student Run Clinic and other student-run free clinics across the country.
The latter, free clinic would have been better suited to Mr. T and his financial situation, as these clinics are explicitly designed to help patients who are uninsured and impoverished.
The onus is on those in health care and mental health to address these issues afflicting substance abusers, and to collaborate with one another to ensure that these people get the best help they can in addressing the condition, which will go on to have life-threatening sequelae.
In the case of alcohol, issues such as liver cirrhosis, hepatic encephalopathy, and the consequences of that aforementioned ‘downward spiral’ have always been, and will continue to be fatal.
Mr. T’s death was a preventable manifestation of years of alcohol misuse, but serves as a learning experience for health care providers and other mental health professionals to prevent future patients with alcohol issues from suffering from the indelible health ramifications and losing their lives the way that Mr. T did.
Hudak PL, Wen CK, Hwang SW. Homeless people’s perceptions of welcomeness and unwelcomeness in healthcare encounters. J Gen Intern Med. 2007;22(7):1011-7.
Keyes KM, Hatzenbuehler ML, McLaughlin KA, et al. Stigma and treatment for alcohol disorders in the United States. Am J Epidemiol. 2010;172(12):1364-72.