CDC: Rural-Urban Gap Persists in PCP Opioid Prescribing

Opioid prescribing rates are significantly higher in rural areas, though overall opioid prescribing has declined since 2016, according to the latest numbers from the Centers for Disease Control and Prevention (CDC).

Macarena C. García, DrPH, with the CDC’s Center for Surveillance,

epidemiology, and Laboratory Services, and colleagues report their findings in an article published online recently in Morbidity and Mortality Weekly Report.

García and colleagues analyzed national data from 31,422 primary care providers in the Athenahealth electronic health record (EHR) system from 2014 to 2017. They found that the prevalence of opioid prescriptions was 87% higher in the most rural counties compared with large metro counties (9.6% vs 5.2%).

The authors offered some context for the trend.

“Opioid prescribing in rural (nonmetropolitan) areas is strongly influenced by providers’ individual relationships with their patients, and can be inconsistent with opioid prescribing guidelines,” the authors write.

They also note that higher prescription rates in rural areas may be linked with higher use and misuse of prescription drugs at a younger age and higher prevalence of chronic pain among those in rural areas.

Rural areas also tend to have a higher percentage of older adults, a population with more conditions associated with pain, they note, and residents of rural areas may have less access to alternative treatments for pain.

“As less densely populated areas appear to indicate both substantial progress in decreasing opioid prescribing and ongoing need for reduction, community health care practices and intervention programs must continue to be tailored to community characteristics,” the authors write.

The report points out that overall opioid prescribing rates have been declining since March 2016 after the release of the CDC Guideline for Prescribing Opioids for Chronic Pain.

Among other findings in the report:

  • Of 70,237 fatal drug overdoses in 2017, prescription opioids were involved in 17,029 (24.2%);
  • In 2017, 14 rural counties were among the 15 counties with the highest opioid prescribing rates, which put patients at greater risk for addiction and overdose.
  • Drug overdose is the leading cause of unintentional injury–associated death in the United States.

Among limitations of the study are that the data did not indicate the circumstances of the prescribing, such as whether a patient had chronic or acute pain, or whether prescriptions were filled and taken as the provider prescribed.

The authors write that this study shows that EHRs can help supplement traditional surveillance.

They add, “The lag between the collection of the data and this analysis could potentially be reduced to a matter of weeks with optimized workflows.

Opioid-Related Deaths Up Threefold in Children

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The mortality rate from opioid poisoning among children and adolescents in the United States increased almost threefold between 1999 and 2016, a new study shows.

The increase was most profound among those aged 15 to 19 years, a group that sustained a substantial rise in deaths from heroin and synthetic opioids.

The study found that opioids were responsible for almost 9000 deaths among children and adolescents during the period studied and that almost 40% of them died at home.

The opioid crisis should be viewed as a “family problem,” where “everyone is affected and likely exposed” when these drugs are brought into the home, lead author Julie R. Gaither, PhD, an epidemiologist and instructor, Department of Pediatrics, Yale School of Medicine.

“I would love it if physicians who treat adults with opioids would consider who else is in the household, whether it’s an elderly family member or children.”

Gaither stressed that although the opioid epidemic is complex, some of the answers to it “are just common sense,” and these include “basic safety measures” such as telling patients that an opioid can kill a child.

The study was published online December 28 in JAMA Network Open.

The authors report that almost 5000 children under age 6 years are evaluated every year for opioid exposure in emergency departments across the United States. Hospitalizations for opioid poisonings increased almost twofold among children and adolescents between 1997 and 2012.

However, it’s unclear how many children die each year from opioid poisonings and how mortality rates have changed over time since the opioid epidemic began in the late 1990s.

For this new study, researchers used the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER). This database includes US county-level death certificate data from the National Center for Health Statistics.

Investigators identified poisonings from prescription and illicit opioids between January 1, 1999, and December 31, 2016. They used International Statistical Classification of Diseases, 10th revision (ICD-10) codes to categorize deaths from any opioid.

Under the label “prescription opioids,” Gaither and colleagues grouped all but synthetic opioids. The exception was methadone, a synthetic opioid that was included in the prescription category.

The other synthetic opioids (including pharmaceutically and illicitly manufactured fentanyl) and heroin were assessed separately and only in adolescents aged 15 to 19 years.

Researchers classified deaths as unintentional, suicide, homicide, or undetermined.

They categorized children and adolescents by age group: 0 to 4 years, 5 to 9 years, 10 to 14 years, and 15 to 19 years.

In the oldest age group, researchers also examined deaths involving one or more other drugs.

Researchers used a generalized smoothing spline Poisson regression model to estimate mortality rates and assess temporal changes in rates over time (time effect).

They found that 8986 children and adolescents died from prescription and illicit opioid poisonings between 1999 and 2016. Of these, 88.1%, were aged 15 to 19 years, and 6.7% were under 5 years. Most deaths were among non-Hispanic whites (79.9%) and males (73.1%).

During the study period, the annual estimated mortality rate for all children and adolescents rose from 0.22 (95% CI, 0.19 – 0.25) to 0.81 (95% CI, 0.76 – 0.88) per 100,000, an increase of 268.2% (for time effect < .001).

Broken down by age group, the increases in mortality rates (all for time effect < .001) were:

  • Ages 0 to 4 years: From 0.08 (95% CI, 0.06 – 0.10) to 0.26 (95% CI, 0.22 – 0.31) per 100,000, an increase of 225.0%.
  • Ages 5 to 9 years: From 0.02 (95% CI, 0.01 – 0.03) to 0.04 (95% CI, 0.03 – 0.06) per 100,000, an increase of 100.0%.
  • Ages 10 to 14 years: From 0.04 (95% CI, 0.03 – 0.06) to 0.10 (95% CI, 0.07 – 0.13) per 100,000, an increase of 150.0%.
  • Ages 15 to 19 years: From 0.78 (95% CI, 0.68 – 0.88) to 2.75 (95% CI, 2.55 – 2.96) per 100,000, an increase of 252.6%.

The authors noted that children under 5 years, who they called “a highly vulnerable group for which the consequence of the opioid crisis has been somewhat overshadowed by opioid-related morbidity among neonates and older teens,” had the second highest mortality rate.

Systemic Problem

The overall mortality rate for males increased by 241.9%, compared with 323.1% for females (all for time effect < .001).

“Most poisonings are still in males, and in white males in particular, but rates are rising at a faster rate among girls as well as among Hispanics and blacks,” commented Gaither. Black children had almost a fourfold increase in rates.

“This is indicative of the fact that this is a systemic problem and it’s continuing to spread to all segments of society,” she said.

Among non-Hispanic white children and adolescents, mortality rates increased by 289.3%.

About 80.8% of deaths were unintentional, 5.0% were because of suicide, and 2.4% were attributed to homicide.

But the manner of death varied significantly by age group. Among those 15 to 19 years, 85.3% of deaths were unintentional and 4.8% were attributed to suicide, while among children under 5 years, 38.0% of deaths were unintentional, 24.5% were because of homicide, and the manner of death could not be determined in 37.5% of cases.

The percentage of deaths because of homicide was highest in those younger than 1 year (34.5%).

Anecdotal evidence suggests parents may be giving their child an opioid to sedate them or help get them to sleep, commented Gaither.

Prescription opioids were implicated in 73.0% of deaths. Methadone alone caused 35.9% of prescription opioid deaths; however, the mortality rate for methadone peaked in 2007 and by 2016 had decreased by 76.7%.

Heroin was responsible for 23.6% of deaths among adolescents aged 15 to 19 years. Rates for fatal heroin poisonings in this group increased by 404.8%, whereas rates for prescription opioids increased by 94.7% (all for time effect < .001).

Huge Surge

In this age group, mortality rates for synthetic opioids increased by 2925.0% (for time effect < .001).

“For synthetic opioids, the rates were essentially flat until about 2014, and then there was a huge surge,” said Gaither. “Over time, there was this almost 3000% increase in deaths from synthetic opioids, and since 2014, a third of all poisoning deaths — so prescription, everything — were due to synthetic opioids.”

Among older adolescents, 38.5% of deaths involved another prescription or illicit substances in addition to an opioid. These included benzodiazepines (19.6%), cocaine (11.6%), alcohol (6.6%), antidepressants (4.1%), psychostimulants (4.0%), cannabis (1.6%), antipsychotics/neuroleptics (1.2%), or barbiturates (0.3%).

Almost two thirds of deaths (61.6%) occurred outside of a medical facility, with 38.0% occurring at home or other residential se

Gaither said she was surprised at the high number of opioid poisonings every year in kids. “There has been a perception that few kids actually die from opioid poisoning.”

Contributing to the surge in opioid-related deaths in kids is the sheer number of these drugs now available, which increases the chances that children will be somehow exposed.

Teens, for example, may find the drugs in the medicine cabinet or in their mother’s purse, while younger children may come across part of a drug strip on the floor or counter and put it in their mouth.

“We don’t have child-proof packaging on all opioids, including the fentanylpatch [Duragesic] and Suboxone,” the combination form of buprenorphine and naloxone used to treat opioid addiction, said Gaither.

Duragesic comes in foil wrappers that can be easily opened by a child, and Suboxone, now sold in brightly colored film strips, also poses a danger to children, she said.

The rate of opioid poisoning among young people could increase further with initiatives aimed at increasing the availability of naloxone in homes and communities, especially given that most pediatric deaths occur outside a medical setting.

“I personally am not sure how that affects very young kids,” said Gaither. “I think we need further research to be able to say what parents of young child should be doing.”

She urged clinicians to consider the individual patient in the context of the family “and to think about how everyone in the home is affected and likely exposed to opioids.”

The study relied on data from death certificates, so it’s possible that misclassification of cause and manner of death occurred, the researchers noted.

Tip of the Iceberg

Asked to comment for, Lloyd Werk, MD, MPH, chief, Division of General Pediatrics, Department of Pediatrics, Nemours Children’s Health System, Orlando, Florida, said the new study “reveals the extent of opioid deaths that had not been known in pediatrics.”

But the surge in opioid deaths is just “the tip of the iceberg,” said Werk.

“With this study showing so many youth experiencing opioid deaths, that tells us there are even more youth experiencing mental and physical consequences from opioids, including depression, anxiety, school failure, risk for illnesses like hepatitis, and pregnancy.”

Such consequences can even include heart infections because of intravenous drug use and stroke, he added.

Because of the increased consequences of opioid use, it’s even more important to screen young people for drug use.

Several screening tools are available. Some of the more well-known are SBIRT (Screening, Brief Intervention, and Referral to Treatment) and HEADSS (Home, Education/Employment, Peer Group Activities, Drugs, Sexuality, and Suicide/Depression).

Results of screening can give youth positive reinforcement if they’re staying away from drugs, and if they’re struggling, support and referrals can be provided, said Werk.

Are kids likely to be honest about their drug use? “If it becomes a routine part of regular office visits and is done confidentially without the parents in the room, there is evidence that there is a decent response,” said Werk.

But the first step is to just ask youth about drug use. “If you ask the question early enough, you can potentially save a life.”

Primary care physicians generally start such screening at about age 11 or 12 years, said Werk.

Some research has linked drug use in youth, along with mental health problems and poor health, to earlier exposure to events such as divorce, abuse, and a parent being incarcerated. 

“If we can identify folks at risk, maybe we help them build resilience, build their ability to cope,” he said.

The fact that some prescribed opioids are still not in childproof packages is “crazy,” Werk added. “Here you have a substance that can cause you to stop breathing, especially if you’re a toddler, and that’s potentially fatal. We could do a better job of child-proofing containers that hold opioids.”

Endorsing Cannabis as an Opioid Substitute ‘Irresponsible’

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Even as two states have passed laws to encourage clinicians to use cannabis as a substitute for opioids, some experts are warning against this practice.

Two addiction experts — Keith Humphreys, PhD, professor of psychiatry and behavioral sciences at Stanford University, Palo Alto, California, and Richard Saitz, MD, professor and chair of the department of community health sciences, Boston University School of Public Health, Massachusetts — argue that “substituting cannabis for opioid addiction treatments is potentially harmful.”

Saitz, who is also a former director of Boston Medical Center’s Clinical Addiction Research and Education Unit, said he and Humphreys decided to write the article, which was published online February 1 in JAMA, because patients and physicians have been “chattering” about cannabis as an opioid substitute.

“The conversation has generally assumed cannabis to be safer and as effective as opioids, but it isn’t clear what the truth is.”

Thirty-three states, Washington, DC, Guam, and Puerto Rico have legalized cannabis for medical use, and 10 states and Washington, DC, have legalized it for recreational use, according to the National Council on State Legislatures.

Both New York and Illinois recently amended medical marijuana laws in favor of cannabis as a substitute, which was another factor in writing the article, said Saitz.

New York issued emergency regulations in July 2018 allowing opioid users to become certified to use medical marijuana instead. In August 2018, the Illinois governor signed a bill allowing individuals over age 21 with conditions for which opioids might be used to apply for the medical marijuana program.

“Irresponsible” Recommendation

“The suggestion that patients should self-substitute a drug (ie, cannabis) that has not been subjected to a single clinical trial for opioid addiction is irresponsible and should be reconsidered,” Saitz and Humphreys write.

“There are no randomized clinical trials of substituting cannabis for opioids in patients taking or misusing opioids for treatment of pain, or in patients with opioid addiction treated with methadone or buprenorphine,” they add.

There is “low-strength” evidence showing that cannabis can alleviate neuropathic pain, and insufficient evidence for other types of pain, and the studies are of poor quality, said the authors.

Saitz and Humphreys noted that some have said that allowing cannabis use instead of opioids has led to fewer overdoses. But, they said, “correlation is not causation.”

The only individual-level study to look at this issue, published in the Journal of Addiction Medicine in 2018, found that “medical cannabis use was positively associated with greater use and misuse of prescription opioids,” they said. A regression model study published last fall in the American Journal of Psychiatry reached a similar conclusion: that cannabis use increased the risk of developing nonmedical prescription opioid use and opioid use disorder.

Saitz and Humphreys said proponents of substitution often overlook the risks of cannabis, which include motor vehicle crashes, cognitive impairment, structural brain changes, and psychotic symptoms. There is also a risk of cannabis addiction, they said.

The authors said that if cannabis is to be used as medicine, it should be subjected to the same types of trials and regulation as medical therapies.

“Cannabis and cannabis-derived medications merit further research, and such scientific work will likely yield useful results,” they said. “This does not mean that medical cannabis recommendations should be made without the evidence base demanded for other treatments,” they write.

Ineffective Pain Reliever

Asokumar Buvanendran, MD, chair of the American Society of Anesthesiologists (ASA) Committee on Pain Medicine and a professor of anesthesiology at Rush University Medical Center, Chicago, Illinois, agreed that “there is not enough research and science” on cannabis, but added, “we need to support further research.”

The ASA has supported moving marijuana to schedule II on the Drug Enforcement Administration’s list of controlled substances, which would facilitate more research, Buvanendran told Medscape Medical News.

Even though he practices in Illinois, he said that he does not believe awareness of the changes to the state’s medical marijuana law is widely known.

Buvanendran said he’d counsel patients seeking to substitute cannabis to consider alternatives — such as injection therapies and surgical procedures to modulate nerves causing pain — which have a larger evidence base.

Kevin Boehnke, PhD, a research investigator in the anesthesiology department and Chronic Pain and Fatigue Research Center at the University of Michigan, Ann Arbor, who has written a lot on cannabis and chronic pain, said that most cannabis trials have methodological flaws and “the evidence for opioids for chronic pain management is quite poor.”

He also notes that the studies generally do not distinguish between tetrahydrocannabinol (THC), which is psychoactive, and cannabidiol (CBD), the other most prevalent active ingredient. THC is associated with most of the health risk of cannabis, while CBD products have limited abuse potential, Boehnke said.

Boehnke believes cannabis offers less dangerous side effects and a lower risk of addiction — although he would advise against use in people with substance use disorders. Both opioids and cannabis are relatively ineffective pain relievers, “but one of them can kill you and one can’t,” said Boehnke, adding, “to me, the risk-benefit is obvious.”

Need for Better Evidence

He added that he is looking forward to a time when there is better evidence to guide clinicians, particularly given that he and his colleagues recently published data suggesting that potentially more than a million Americans are using medical marijuana.

In that study, published in the February edition of Health Affairs, the researchers queried states with medical marijuana laws in an attempt to gauge how many Americans have registered and what conditions they were treating with cannabis.

Data were available from 20 states and Washington, DC; Connecticut does not publish reports on users and did not respond to requests for data and 12 states said they don’t have statistics.

Chronic pain was the most common patient-reported condition, accounting for 62% of the total conditions reported, followed by multiple sclerosis spasticity. Those are also the two conditions with the largest evidence base and among the most common conditions required for medical marijuana certification in most states, Boehnke said.

And chronic pain affects some 100 million Americans, so it is no surprise that it is the most common condition that individuals are seeking to treat, he said.

Even though the lack of reports from some states likely underestimate the number of patients using medical marijuana, “our data show that the number of medical cannabis patients has risen dramatically over time as more states have legalized medical cannabis,” said Boehnke and colleagues.

The gap in statistics on the number of users and conditions they are treating highlights “the importance of compiling a nationwide database of medical cannabis users to evaluate the risks and benefits of using medical cannabis for different medical conditions and symptoms,” said the authors.

HHS Advises Coprescribing Naloxone and Opioids

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“We have begun to see some encouraging signs in our response to the opioid crisis, but we know that more work is required to fully reverse the decades-long epidemic. Co-prescribing naloxone when a patient is considered to be at high risk of an overdose, is an essential element of our national effort to reduce overdose deaths and should be practiced widely,” Giroir said.

The opioid overdose reversal drug naloxone (multiple brands) should be prescribed to all patients at risk for opioid complications, including overdose, according to new guidance released today by the US Department of Health and Human Services (HHS).”Given the scope of the opioid crisis, it’s critically important that healthcare providers and patients discuss the risks of opioids and how naloxone should be used in the event of an overdose,” Adm. Brett P. Giroir, MD, HHS assistant secretary for health and senior advisor for opioid policy, said in a news release.

To reduce the risk for overdose deaths, the new guidance recommends that clinicians “strongly” consider prescribing or coprescribing naloxone to the following individuals:

Patients prescribed opioids who:

  • Are receiving opioids at a dosage of 50 morphine milligram equivalents per day or greater
  • Have respiratory conditions such as chronic obstructive pulmonary disease or obstructive sleep apnea (regardless of opioid dose)
  • Have been prescribed benzodiazepines (regardless of opioid dose); have a nonopioid substance use disorder, report excessive alcohol use, or have a mental health disorder (regardless of opioid dose)

The guidance defines individuals at high risk of experiencing or responding to an opioid overdose as those:

  • Using heroin or illicit synthetic opioids or misusing prescription opioids
  • Using other illicit drugs such as stimulants, including methamphetamineand cocaine, which could potentially be contaminated with illicit synthetic opioids like fentanyl
  • Receiving treatment for opioid use disorder, including medication-assisted treatment with methadonebuprenorphine, or naltrexone
  • With a history of opioid misuse who were recently released from incarceration or other controlled settings where tolerance to opioids has been lost

The guidance also advises clinicians to educate patients and those who are likely to respond to an overdose, including family members and friends, on when and how to use naloxone in its variety of forms.

“Promoting the targeted availability and distribution of overdose-reversing drugs is one of the five pillars of HHS’s comprehensive, science-based strategy for the opioid epidemic,” HHS Secretary Alex Azar said in the release.

“This new guidance reflects our commitment to ensuring those who need overdose-reversing drugs have them and provides practical steps that clinicians, patients, and the public can take to reduce the risk of an overdose,” Azar said.

In April 2017, HHS put forth its 5-Point Strategy to Combat the Opioids Crisis. Those efforts include better addiction prevention, treatment, and recovery services; better data; better pain management; better targeting of overdose reversing drugs; and better research.

In April 2018, US Surgeon General Jerome M. Adams, MD, issued an advisoryencouraging more individuals, including family, friends, and those who are personally at risk for an opioid overdose, to carry naloxone.

No Safe Limit’: Even One Drink a Day Increases Risks

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Alcohol consumption is responsible for 2.8 million deaths per year across the globe, with cancer the leading cause of alcohol-related death among people aged 50 years and older, warn researchers, who also emphasize that there is no safe level of alcohol consumption.

The findings come from the latest version of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), which analyzed data on 28 million people from 195 countries to estimate the prevalence of alcohol consumption, the amounts consumed, and the associated harms.

The report was published online in the Lancet on August 23.

The analysis found that among individuals aged 15 to 49 years, alcohol accounted for around 4% of deaths in women and 12% in men. Tuberculosis and road injuries were the leading causes of death related to alcohol.

For those aged 50 years and older, alcohol was linked to 27% of deaths in women and 19% of deaths in men, with cancer the leading cause of alcohol-related death.

Overall, consuming just one drink a day increased the risk of developing alcohol-related health problems by 0.5% vs abstaining; drinking five drinks a day led to 37% increase in risk.

Lead author Max G. Griswold, MA, Institute for Health Metrics and Evaluation, University of Washington, Seattle, said in a release that although previous studies have suggested that alcohol is protective against some conditions, “we found that the combined health risks associated with alcohol increase with any amount of alcohol.

“In particular, the strong association between alcohol consumption and the risk of cancer, injuries, and infectious diseases offset the protective effects for ischemic heart disease in women in our study,” he said.

“Although the health risks associated with alcohol starts off being small with one drink a day, they then rise rapidly as people drink more,” he added.

The new findings echo those from in the 2014 World Cancer Report, which found a dose/response relationship between alcohol consumption and certain cancers.

Griswold calls for public health policies to focus on “reducing alcohol consumption to the lowest level” and to revise the “widely held view of the benefits of alcohol.”

Coauthor Emmanuela Gakidou, PhD, also from Institute for Health Metrics and Evaluation, went further, declaring: “Alcohol poses dire ramifications for future population health in the absence of policy action today.

“Our results indicate that alcohol use and its harmful effects on health could become a growing challenge as countries become more developed, and enacting or maintaining strong alcohol control policies will be vital,” she said.

She suggested that countries look at measures such as excise taxes and controlling the availability and advertising of alcohol.

“Any of these policy actions would contribute to reductions in population-level consumption, a vital step toward decreasing the health loss associated with alcohol use.”

In an accompanying comment, Robyn Burton, PhD, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, and Nick Sheron, MD, Division of Infection, Inflammation and Immunity, University of Southampton, United Kingdom, say that the results are “clear and unambiguous.”

The Twelve Stages to an Alcoholic Life

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This was submitted to us from a fellow traveler in  recovery. We think it makes some valid points and hereby pass it on.

AA teaches that there are no levels or stages of alcoholism. Alcoholism is alcoholism and drunk is drunk. I don’t agree with that analogy. It is my experience there has been definite advancements within my alcoholics drinking life. This is how I see it:

STAGE ONE – It’s just a few beers and a football game.

You wouldn’t recognize an alcoholic in this stage. One might see a person just having a good time. He is still able to get to work on time, do a good job and meet daily responsibilities. But when the weekend comes, there’s always a reason to drink – SuperBowl, New Year’s Eve, Barbeque, Graduation, Birthday parties… there’s always something going on involving alcohol. It doesn’t appear to be so bad because he’s a family man and he is always there for his wife and kids.

STAGE TWO – It’s five o’clock somewhere.

Drinking has progressed now to happy hours after work. He gets home from work later and may already be drunk by the time he gets home. Drinking will now take him away from home more often than not. He prefers to drink with people who share his drunkenness. He still may find time for the wife and kids, but they are no longer his top priority. He may lie about the amount on his paycheck to hide money outside the regular budget. And the budgeting responsibility falls more on the shoulders of the non-alcoholic.

STAGE THREE – Working gets in the way of my drinking.

By this time, he may have lost a job or two because he has neglected his duties as an employee. Lunch hours will be drinking hours and usually last longer than a normal hour. Leaving work early and not getting home until well into the night is more common. No need to wait for him to join you and the family for dinner, because when he does show up he goes straight to bed to pass out. He will not be able to account for most of his paycheck because he will lose it, give it away or drink it away. His real friends will stop spending time with him because he is not fun anymore. The only friends he has now are the ones he met at the bar last night.

STAGE FOUR – I think I have food poisoning.

Employment is a faint memory. His day starts with a cup of vodka and a coffee chaser. By noon, he must take a nap because if he doesn’t he will fall down and pass out wherever he is at the moment. His eating diminishes and he complains that his stomach is always upset. His skin begins to turn a jaundiced shade of yellow. Nosebleeds are commonplace and he will pick at every sore on his body until they bleed. He no longer contributes to the household responsibilities and the non-alcoholic becomes a single parent. Since he’s incapable of driving to the bars, the few friends he had are now no longer around. He is left with only his family and their constant pleading for him to get help.

STAGE FIVE – I want to see a doctor.

He knows there’s something wrong and thinks maybe a doctor can fix it. But, he doesn’t want to stop drinking so the doctor must be able to work some magic that will allow him to drink and get well at the same time. He still does not understand that the drinking is what is making him ill. He is probably sleeping during the day and awake at night. His memory is all but gone and may confuse people, places and times. He may not know for sure where he is or how he got there. Inappropriate behavior may start occurring, i.e, using crude language around very small children and/or not putting on pants while there are visitors. No one wants to visit. Miraculously family members are tolerant but disgusted by his behavior.

STAGE SIX – Why bother to detox?

The only way to save his life is by detoxification. The liver is no longer functioning at an optimal level and toxins are not being removed from his blood stream. A result is a high level of ammonia accumulating in his frontal lobe of the brain. His kidneys may be shutting down and he may be bleeding internally. His skin and eyes are a sickly yellow and may even become florescent. He is as demanding as a three year old in an ice cream parlor. Irrational reasoning and convoluted thinking become his daily entertainment. At this stage, he is close to death’s door.

STAGE SEVEN – You’re not going to make it.

At this point there are two choices – detox or not to detox. Detoxing has its own risks and doesn’t mean the alcoholic will recover from his self-abuse. Not detoxing is a certain death sentence. Neither choice holds much hope. But, they are the only options on the table.

STAGE EIGHT – In memoriam

The non-alcoholic is now grasping at vague memories of happier times so that she will have something – anything – good to say at his funeral. There are conflicting emotions – if he dies, it will be a relief. It will be over.  If he survives, the entire process could be repeated. Or he could recover, rehab, and stop drinking – become a happy productive member of society.

STAGE NINE – What!! You’re still alive!!

He makes it through. It will still be a long road to recovery, but he will be just fine. He decides to go to rehab because he realizes now that he has been walking down the wrong path. The family is ecstatically happy and they vow to aid in his rehabilitation. They offer to do whatever it takes – to understand everything they didn’t understand before. They want to support in his recovery.

STAGE TEN – I must be selfish because I’m in recovery.

A regiment of 12-step meetings begins and nothing else matters. He’s never available because he must go to a meeting. Tunnel vision develops and 12-step groups become his only focus. He’s just as unavailable as he was during drunkenness. But how can his supporters do anything but support his quest for enlightenment?

STAGE ELEVEN – I’m stronger than alcohol.

And because I’m stronger than alcohol, I can have a beer or a glass of wine with dinner. He believes he is invincible and the drinking starts again. Small doses at first, then he is suddenly back to STAGE FOUR or any of the other following stages. The first time the repeat happens a feeling of disbelief that he could do this again is shocking to the family.

STAGE TWELVE – Haven’t we met before?

The cycle continues from whatever stage he returns to after resumption of drinking. It can resume at any stage. The more times he goes through detox or rehabs the more likely that he will resume to a stage closer to Stage Eight. It’s a never ending circle. The trick for the non-alcoholic is to try not to be in the center of the circle while it’s forming.