Sunday, May 14, 2017

Patients Who Drink Too Much

When I am facing an alcoholic in the office, I do not advise him to stop drinking.  Other physicians may advocate a different approach.  We live in a free society and individuals are free to make their own choices.  I have decided, for example, not to own a firearm, ride a motorcycle or bungee jump as these activities are not only beyond my risk tolerance threshold, but are also activities that I have decided would not enrich my life.  Many smokers, though addicted, enjoy the experience and are aware of the risks of this activity. 

Preparing One for the Road

My responsibility as a physician is to inform and counsel, not to lecture or preach.  I tell alcoholics with clear candor the medical risks they face if they decide to maintain this lifestyle.  I advise them that if they wish to aspire to sobriety, that I will refer them to appropriate professionals for treatment.  I further inform them that in my decades of experience, very few alcohol addicts can quit on their own, despite their vigorous declarations that they can do so.  Finally, I tell them that if they decide to venture on the difficult journey away from wine and spirits, that I will be there at every step to assist and encourage them.  However, there is no hectoring or finger-wagging from me.  No threats or intimidation – which never work anyway - just cold facts and honest predictions.  The patient is then free to make his decision, as he is with any medical proposal.

Patients aren't obligated to accept my advice.  Indeed, the bedrock concept of informed consent places the authority of the decision where it properly resides, with the patient.  

Alcoholsim is an insidious disease whose tentacles slowly suffocate the addict and causes many friendly fire casualties.  Yes, I am aware that there may be a genetic predisposition to the illness, but at some point the decision to drink was still a choice.  Ultimately, only the afflicted one can cast off the chains. 

What do you think?  Am I derelict by not delivering an energetic exhortation, “You’ve got to stop your drinking!”  Is it my job to tell patients what to do, or to give them a fair presentation of their options so that they can choose for themselves?  


  1. Agree with you on informed consent and your approach. Lectures never work.
    I have personally concluded that many addictive behaviors are at root due to some sort of adverse childhood experience, and my own life supported this, so I'm admittedly biased. gabor mate has some books/research regarding this.

  2. Agree entirely

  3. Fully agree with your informed consent approach. I bet you "converted" more patients then doctors who constantly force patients to stop.

    I am very interested in this - do you saying "very few alcohol addicts can quit on their own" to tickle motivation or just as a fact?

  4. Talking about stopping has little impact on alcoholics who do one thing extremely well; they are experts at denial. Talking about sparing them the pain of harming others in a car accident, or during domestic violence, or by bankrupting the family so children go hungry may help the person see the error of their ways. They have the right to harm themselves but not others. If this does not work, then asking them whether their family would be better off without them may make them either quit or commit suicide. Happily one is an improvement for all concerned but sadly the other is still an improvement for all concerned.

  5. Having practiced addiction medicine for over 20 years I agree with your approach. It fits with what we have learned about the stages of change. One of the factors that helps an addict change is a sense of being emotionally connected to someone who is sober. Your approach creates the opportunity for them to make such a connection with you. A lecturing approach leaves no such opportunity. Your approach therefore increases the probability that the person using alcohol will reduce or stop. Thanks for posting on this topic.