The sudden death of 27-year-old recording artist Amy Winehouse, in circumstances related to her abuse of alcohol and illicit substances, proves not only that alcoholism and drug dependence can be lethal, but that strategies to control it sometimes must be extremely aggressive and unrelenting—even if that means, for example, having the person formally declared incompetent, hospitalizing that person against his or her will a dozen times on a locked psychiatric unit or literally watching that person swallow Antabuse (which causes extreme, emergent physical distress when combined with alcohol) every single day.
I have treated alcohol and drug dependent individuals for well over 15 years. Some were homeless. Some were extremely wealthy. Some were living on the margins of society and had been imprisoned multiple times. Some had served in public office at the highest levels. What a number of them had in common was that, regardless of socioeconomic status, they seemingly lacked the capacity to stop drinking or using drugs. They were truly “powerless” over the substances to which they were addicted. They were as nearly hopelessly attached to their substances as any lover in a destructive relationship could be.
The idea that an alcoholic or heroin addict or cocaine addict may have to “hit bottom” in order to decide to begin climbing back to health is a theory associated with 12-step groups like AA. It has become widely accepted by the public. But, for some folks, “bottom” is six feet underground, and preventing catastrophe calls for a war to be waged by others on behalf of the alcoholic or drug addicted person.
Yes, addicts must eventually sign on with sobriety and demonstrate their own resolve to remain sober. And, yes, it is true that “tough love,” in which family members withhold resources, in hopes that addicts will stop believing they can drink and still enjoy support, has its place. So, too, however, does a clinician’s resolve that the addict will simply not be allowed to drink herself or drug herself to death.
This is why I have told many patients (including some referred as a condition of probation after drug driving arrests) that, because of their past behavior while intoxicated, I will require them to take random drug tests and will automatically commit them to locked psychiatric units if I learn that they have begun drinking or using drugs again (or if they refuse the tests).
I also consider the use of Antabuse—which interrupts the metabolism of alcohol at a toxic byproduct—my ally in keeping alcoholics sober. If an alcoholic takes Antabuse in the morning, drinking that day or night (or the next day) is likely to cause severe symptoms, including skyrocketing blood pressure, nausea and even death. Not
infrequently, I insist that a family member (or that I) actually observe the alcoholic take his or her
Antabuse (crushed and dissolved in water, to prevent spitting the medicine out later or throwing it up). Naltrexone can serve a similar purpose for those addicted to opiates.
On occasion, I have electronic bracelets applied to patients’ ankles that automatically monitor their perspiration for any alcohol content. The data is transmitted to a base station in a family member’s home.
I coach families on how to go to court and get medical or legal guardianship (or both) over those alcoholics who simply won’t stop drinking and are at risk of severe health consequences (or severe legal consequences) because of it. I put them in touch with attorneys skilled in mental health law to make their cases for them in court. And, almost without exception, they win.
I have had several patients actually relocate for extended periods of time (sometimes years) to the area in which my office is located in order to give me the proximity, access and authority to keep them from their self-destructive addiction.
By no means do I find it necessary to deploy this intense strategy in every case of alcoholism or illicit substance dependence I treat. And I am always careful to attempt at every moment to give alcoholics and drug addicts maximal autonomy to choose health and safety and sobriety for themselves. But I do not hesitate to step in when they will not. Because I am not willing to lose patients under my care to a mental illness without firing every, single arrow in my quiver of clinical and legal arrows.
I have lots.
I have asked patients before, “Are you sure you want to work with me to defeat your addiction? Because if you are, I’m not going to be shy about trying.”
If Amy Winehouse could not take responsibility for her own well-being, she should not have had that responsibility. Long ago, her loved ones should have obtained substituted judgment over her, required her to submit to random drug screenings and recruited a psychiatrist willing to hospitalize her each and every time one of those drug screenings turned up positive.
Keith Ablow, MD is a psychiatrist, and was host of the nationally-syndicated "Dr. Keith Ablow Show." He is a former member of the Fox News Medical A Team.