The past three months have been really florid for me professionally. I’ve had three papers come out, and given about 4 talks to audiences of varying size and background. The professor at VFU who oversaw the funding of my grant and I had a conversation about me possibly teaching a class there in the department of health management. Which would allow me to put another “Adjunct Professor” title on my CV. My current adjunct position at ILU is being extended, and my collaborator there is trying to get funding for further development and academic ventures (i.e., my salary).
Tomorrow, I’m meeting with a local research director of the hospital, also associated with VFU, which is part of the same chain of hospitals as my former institution. I wrote an R01eq a few cycles ago that got very well reviewed – but just missed funding – and is still eligible for resubmission. This is the R01eq I wrote for 3 years and about $500,000, for which many told me I was totally insane. But I was specifically told in the summary statement that the budget and timeline were strong factors in my favor. My philosophy being that cheap, innovative science might get a little bit of a boost.
However, MECMC’s mission and the research department I’m meeting with tomorrow are not entirely compatible. I’m reasonably certain that MECMC is not up for selling my time. I could go to 125%, but I’m not sure I want to. Especially if I’m sort of already at 125% because of my gig at ILU. Mostly, I want to impress upon the local other hospital that I can be of use to them. It’s a plan B situation.
But I have a lot of possibilities. And I feel like I’m doing well where I am. I keep getting talked about at the highest levels of MECMC’s administration. In good ways. I’m hopeful of many things flourishing. I’m putting in an R18 here in the spring. I’m looking to meet with the other affiliated hospital at VFU, in order to see if some of my ideas for emergency department analysis would be of value there.
And it looks like a serendipitous tweet exchange will result in a small project and publication! Which is super exciting! I love working in the world of ideas that impact lives. It’s exciting. I think I’m at least reasonably good at it. But right now, I’m deeply ready for a major vacation.
Infactorium is about to go on a reasonably long hiatus, probably. On March 8th, at 6am, @biochembelle and I will be winging our way from the East Coast of the USA to fair Japan. We have made essentially no plans. Booked the first night’s hotel in Tokyo. Bought the Lonely Planet. After 7 days in Japan, we fly to South Korea for 6 more days. So from late next week until somewhere around the end of March, expect light-to-no blogging. As usual, if you email me your address I will likely send you a postcard. Don’t assume I have your address. I had a phone apocalypse and lost everything.
In the program of Alcoholics Anonymous, steps ten, eleven, and twelve are often called the “maintenance steps”. They encompass all of the previous nine, essentially. Step twelve is often invoked when we talk about working with other alcoholics. When we’re talking to active drinkers, and describing the program to them, or to newcomers, we say we’re doing “twelfth step work”. But the twelfth step actually has three clauses. In its entirety:
“Having had a spiritual awakening as the result of these steps, we tried to carry the message to other alcoholics, and practice these principles in all our affairs.”
I know that many people think that the spiritual nature of AA means that it’s not welcoming to atheists. And while I obviously can’t speak for every meeting, I have never heard anyone say they were uncomfortable in the rooms because they were an atheist. I’ve heard many, many people discuss their atheism in the rooms with no dissent. I use spiritual language sometimes, but I don’t pray. I don’t identify as atheist. But I don’t identify as anything. I generally reject labels for myself, and I generally accept whatever label anyone chooses for themselves.
The second clause is that we try to make sobriety available to anyone and everyone who needs it. Anyone with a desire to stop drinking is welcome at AA. Of course, my own opinion is that not everyone who has a desire to stop drinking necessarily needs AA. When people say “AA doesn’t work for [Some Person or Group]!”, I tend to think they’re right. Because AA doesn’t make people sober. AA provides a framework that, if engaged with willingly, allows us to address the facts of and reasons for our drinking. And a program for living life freely and happily, in whatever circumstances we find ourselves.
Which brings me to the third clause: we practice these principles in all our affairs. The principles of sobriety. I am not likely to relapse because I really want to get drunk. Because, frankly, I don’t want to get drunk. I’m over being drunk. I am not likely to relapse because I want to try a particular type of alcohol. It’s not worth it to me. If I’m going to relapse, it will be most likely, I think, over something like what happened Saturday afternoon.
Saturday afternoon, I got a piece of mail. It was addressed in my handwriting. But my address was the return address. It was my property tax bill, which I had mailed to my mortgage company to pay. To the address they gave me. It was returned-to-sender, unopened. I’m furious about it. I hate paperwork and administrative processes. I am utterly bad at them. The first thought that popped into my head was, “Fuck them, with a bottle of vodka, straight down my throat.”
I know that that won’t make a lot of sense to the non-drinkers in my audience. But we alcoholics, I’m guessing, are pretty much all on a similar wavelength here. I couldn’t fix the problem until Monday. Which meant I had like 36 hours to fret and rage and stomp uselessly. I stormed about ECC and tweeted relentlessly about alcohol and my process in dealing with triggers. I ate really hot Thai food and sweated it all out.
At some point, it occurred to me that the reason that drinking occurs to me in those moments is the anesthesia, and temporal distortion. Getting drunk would numb me, and get me to Monday faster so I could deal with it. At least, that’s what my diseased brain would like me to believe in those moments. It’s a trick. A trap I set for myself to derail everything I’ve accomplished and all the things I’ve achieved and the sobriety I rely on to do it. I have a disease that wants me miserable and then dead. I am powerless over it. Because I know that, I can shrug its weight.
But if I practice the principles of recovery in all my affairs, it becomes much easier. I cannot solve this problem until Monday. I know that come Monday, if I’m sober, I will be able to solve it. I’m powerless until then. Do the things I can do when I can do them. Let go of the rest. And Monday came, and I fixed it when I could, by relying on people who know more than I do.
Then, Monday evening, I noticed that my master bathroom is leaking into my spare bedroom. That’s not ok. I have a plumber coming out today. There’s nothing I can do about the facts. All my stomping and frustration and anger won’t solve it, and just makes my chest contract. My old solution – drink and ignore – won’t fix it either. I have a problem and I know how to fix it. It’s a hassle. But that’s all. I don’t want to spend money on a plumber, but if I have to, I have to. Let go.
I don’t stay sober because I fight my drinking. I have stayed sober because I relentlessly pursue serenity, through a program of action and accountability. Resentment, frustration, control; these are the triggers for my relapse. Surrender, meditation, release; these are the antidotes. Pause and think. Rest and consider. Give up and move on. Do what I can with what I have to make my life better today. And go to bed sober.
OK. I need to start this off with a great big disclaimer. I am not a physician. Being an alcoholic in recovery does not give me special insight into the medicine of addiction. AA’s literature is very clear on this point. It says, “We are not doctors.” It says that in the context of saying that alcoholics should be honest with and listen to physicians. Opinions from members of AA about medicine are not to supersede the medical opinion of an informed physician. This is my opinion based on my experience. Your experience may vary.
The reverberations of Phillip Seymour Hoffman’s death continue to sound in many places. I wrote then that “Physicians keep prescribing opiates to addicts. And it keeps killing us.” Hoffman died in some part (as I understand it) because he was legally – and presumably appropriately – prescribed opiates for pain. This led to abuse of the prescription drugs. Which led to heroin. Which led to death.
I’m not anti-opiates as a medication. As I understand it (poorly) they are a godsend for people who have intense acute pain. I have heard there are serious concerns about prescription opiates being used chronically, and my experience jibes with that. As an alcoholic, I could never, ever take opiates for long-term pain management. I have absolutely no doubt that that would kill me. Similarly, I can not take benzodiazepines. I love them. They’re awesome. They’ll kill me.
But if I were to have major surgery? I’m almost certain to need major surgery at some point in my life. Most of us do and I have a (very) minor heart condition that is likely to require surgical correction at some point in my life. If I have to get my chest cracked, chances are I’ll need opiate drugs to manage the pain acutely after surgery. I’ve had codeine before, as a kid when I had my wisdom teeth removed. I’m pretty sure I’d love to take a fistful of codeine and see where it can take me.
So, how do we manage this? What does it mean to be “clean” and “sober” if we take prescription opiates or narcotics or benzoes? My opinion, which is the one that I have taken from hearing it espoused in AA meetings, and at my rehab, is fairly, I hope, straightforward. I can still consider myself “sober” while taking opiates, narcotics, or benzoes if all of the following are true:
1. The medication is legally and appropriately prescribed by a physician.
2. The physician knows that I am an alcoholic in recovery.
3. I take the medication precisely according to the physician’s instructions.
4. I stop taking the medication as soon as is possible. i.e., as soon as I can endure the pain without anesthesia.
5. I never take the medication with the intent of experiencing mind-altering effects.
Additionally, the following is incredibly highly recommended, but may not be possible in all circumstances (such as acute injury)
6. The physician has experience treating patients with addictions.
Now, obviously, if I am in an accident and an emergency medical technician doses me with morphine at the scene, that’s not a breach of sobriety. Breaches of sobriety require intent. But opiates, narcotics, and benzoes cannot be prescribed to us “PRN”. There needs to be a schedule. It needs to be followed.
My intention for myself is that I will never take any of those medicines as an outpatient. If my pain is severe enough to need opiates, then I need to be an inpatient, under the care of a hospitalist. But the time I’m ready for discharge, I’ll need to be able to take alternative pain medicine. I will suffer pain rather than take any opiate or narcotic. I will suffer anxiety rather than take any benzo. I simply don’t have the option to take these drugs outside of an inpatient environment. They will kill me. I had a root canal with nothing but lidocaine and ibuprofen. I was fine.
I have seen many alcoholics die after being legally and appropriately prescribed pain medications. Even alcoholics with no prior history of abusing anything but alcohol. I have little doubt that I might well number among them if a physician gave me a 30-day supply of hydrocodone with three refills.
Engaging with medical care is always a dicey proposition. As addicts, it is a matter of life or death. We are, almost uniformly, tempted by the “free high” of appropriately prescribed opiates. Because we are addicts and alcoholics. We are tempted by death. I have never found a way to describe just how enticing an alcoholic death can be. But every alcoholic I know understands it.
OK. I’m going to stipulate up front that many of my readers know far, far more about this than I do. My educational background is in engineering, not medicine or epidemiology. I have, however, worked in direct collaboration with professional epidemiologists for many years, and with physicians for two decades, and I’ve taken a short course in epidemiology from the University of Michigan summer sessions. I say this not to argue from authority, but merely to say that I’m not talking entirely out of my ass. I have a minimal background. I do not claim to be an expert.
The course I took at UMich was “reading the medical literature”. Basically, it was a course for med students, residents, and other non-epidemiologists who work in medicine or medical research and need to be able to read and interpret medical papers. Can we critique papers for the quality of their evidence? What are the gold standards? How can we tell if a paper really supports its claims? What makes good a good basis for treatment?
I’m not going to rehash all of that today, but a couple of comments on yesterday’s post got me interested in reviewing the quality of evidence from case studies. Case studies are, by their very natures, anecdotes. There’s a big group of people out there who sort of rally around the cry, “the plural of anecdote is not evidence.” Well, certainly not always, but there is more to evidence than simply the peer-reviewed result of a double-blinded randomized controlled trial too. Evidence comes in many forms. I just learned, 20 minutes ago, of an aphorism (Thanks @amfeinman!) in statistics: “If you have a talking pig, you only need one.”
It is certainly true that the double-blinded randomized controlled trial is the gold standard of medical evidence. But there are other types of studies, like case control studies, which can provide crucial and important evidence. Like, you know, that smoking causes lung cancer . But what kind of evidence do case studies provide?
In my course at UMich, the lecturer (a rather famous Canadian physician and epidemiologist) was adamant: Case Studies are not Evidence. His point was that you can’t generalize from case studies to general practice, and insofar as I’m qualified to argue the point, I agree. A case study is a single event. The information it provides is: “This thing has happened, and therefore can happen.” It does not provide any information about prevalence.
In logic, taking information from a single event and applying it generally is called “specious generalization”. Essentially, it means mixing up an “existence” statement and a “for all” statement. If we have successfully demonstrated that a particular element of a set has a property, it is a specious generalization to say that therefore all elements of the set have that property. While this seems obvious in plain language, it can be subtle in propositional calculus.
In disciplines that aren’t as rigorous – by necessity – as logic is, specious generalization may be required. After all, it is very difficult to prove that anything will be true in medicine for all people. We have to generalize and make assumptions, and apply specific knowledge generally. Also from my UMich course, the instructor said: “The only population that any study applies to for certain is the original study population.” And frankly, even then it may not be so certain. Confounders abound.
So case studies aren’t really evidence, unless they provide a counter example. If we believe that something is always true, and we have a case study where it isn’t, we have evidence that disproves our hypothesis. But that’s rarely the case in medicine. Case studies can also provide important safeguards. A case study of a complication may prove valuable in demonstrating that a technique is flawed, in surgery or anesthesia, for example.
If there are enough case studies that all say the same thing, then yes, they do become evidence of a sort. But generally, they become evidence that an event is worth research. Not necessarily evidence that we should immediately change practice or care delivery. So, those who claim that anything not properly randomized and controlled is nothing but useless anecdote are wrong. Anecdotes are not useless. Evidence comes in many flavors.
So, my take? Case studies are information. Information is valuable. Information can become evidence with further research. And dismissing case studies because they’re anecdotal is foolish.
 Doll R, Hill AB, Smoking and Carcinoma of the Lung. Br Med J. 1950 September 30; 2(4682): 739–748.
I have absolutely no reason to participate in academics. I am not faculty. My job doesn’t require it. In fact, my job is full-time with no academic pursuits whatsoever. Anything I choose to do with regard to publishing, grant writing, mentoring, etc., I do in addition to my regular duties. I don’t have to produce my salary (at least, not with grants), and I don’t have the kind of freedom that being a “real” PI with grant money has. Even if I’m flush with external dollars and paying my own way, I still need permission to attend conferences and whatnot.
No one really reads the papers I write. At least, I don’t think. A paper I published in 2010 on simulation now has a total of three citations, and one of them is me. Another published in 2012 has 5, and I think 3 of them are me. Other simulation work gets cited. Mine is just, well, unimportant. Apparently. It’s not particularly insightful or generalizable. It’s just work. Here’s a thing I did. Essentially case studies. Case studies aren’t evidence.
I can make a difference just doing my work in my hospital. Why am I taking up space in journals? Why am I writing grants and competing with real academics for finite funding resources?
Vanity. I want to be important. I want to be special. I want my friends on twitter to think I’m one of them: an academic producing valuable insights into the world and pushing back the frontiers of ignorance. But I’m not. I’m just a quality improvement engineer who models health care and tries to make his hospital go a little better. I can do that without wasting everybody’s time writing unread reports in minor periodicals. Without siphoning off much-needed grant money from people for whom it represents their livelihood.
I have vague ambitions that I will one day have a real academic post, or that my position here will turn into one. To do that, I’ll need to demonstrate academic credibility. But I don’t actually need any of that. I’m effective and comfortable where I am. I’ve written before that if I have this job for the remainder of my career, I’ll be happy with it.
I just don’t want to leave this world with no written record of my existence in it. I want to have a bibliography that says I was here. I did something useful, for a while. I wasn’t just a drunk who wasted space and time and talent and potential. I was here. That’s my vanity. I want people to know I was here.
Sunday was my sixth sober anniversary. A lot of people use the term “birthday”, and I do too sometimes when not thinking about it. I’m not opposed to it in any way, I just don’t really like it. I have one birthday. I was born of woman in the summer of 1974, and that will never change. On February 16th, 2008, I didn’t drink. Then, for the next six straight years of days, I also didn’t drink. That would be pretty unremarkable, I suppose, except for the fact that I drank close to a bottle of 80 proof liquor a day for many, many years preceding.
But today, as I sit here thinking about the lessons I’ve learned in six years of sobriety, I find myself with little to write about. My life in inestimably better. In fact, I believe my life is inestimably longer. I might very well be dead right now if I had continued to drink. Especially considering how much I drank and drove. And of course, that means that other people’s lives are better and probably longer too.
I get a lot of congratulations when I mention how long I’ve been sober. People tell me it’s an accomplishment. They tell me they’re proud of me. That’s nice to hear, but it also make me sad, sometimes. Because it seems to me that it feeds into the moralism of addiction. I’m no better than an addict who didn’t recover. I may be different in some way, innately, I don’t know. I don’t think anyone knows why recovery finds some and misses others. But I’m not stronger, or smarter, or anything.
People tell me, “Keep up the fight!” But I’m only alive because I stopped fighting. I can’t defeat alcoholism. Recognizing and embracing that is the first step. Literally. I am powerless over alcohol. My life is unmanageable. I don’t battle my addiction. I submit to it. And in fact, I have come to be grateful for it. I’m glad I’m an alcoholic. Because it allowed me to find a way to live, sober, that I never had before. Even before I drank, I was lost. Now I have a map.
Don’t get me wrong. I appreciate the kind things people say. I know how they mean it, and I know that without suffering their own addictions, there is little in the way of a frame that people can put around the picture of recovery. But the language is wrong. And I wonder how other addicts, still active in their addictions, hear it. And then I wonder, what would I have people say instead? Obviously, I want them to say something, or I wouldn’t mention my anniversary at all.
The truth is, I do want credit. I want people to think I’m strong and inspiring and courageous blah blah blah. I want to be admired for facing down and beating a terminal illness. The problem is, it isn’t true. And it just feeds an ego that needs no further stroking. Because the more I feel important and admired, the more I feel ashamed and vile. I still have the alcoholic’s duality. Grandiosity and humiliation, coexisting like a yolk and a white in the same shell.
I am the same degenerate, reprobate, liar, selfish, rancid, angry, lazy, depressed, stupid, nosy, son-of-a-bitch I’ve ever been. I still treat people badly and act selfishly and try to manage things that aren’t my business and inject myself into places that don’t need me. I’m desperate for attention and success and admiration. I’m cocksure and arrogant. I am afraid, all the time.
I act on those things less than I used to. Still not little enough. I have no hope of ever being perfect. I have little hope of ever even being good. I still do and say ugly things. I’m almost forty years old. I’ve had a lot less adult-hood than most of my friends. I’m still figuring out how to be a grown-up. I don’t always recognize when I’m being immature.
Today, I try to balance those things with helping others. With acknowledging when I’ve been wrong. With making amends when I can and they are wanted. I try to balance the dim and hateful view I have of myself with acceptance of the things that I have inside that are worthwhile as well: I’m smart and generous and adventurous. I’m willing to help people who need help with addictions. I’ve done some of that, and I have friends who were drunks who are sober now, and that makes me happy.
I’ve been sober for six years and a day. It’s not nothing. I’d love to take credit for it. But all that can do is walk me closer to a bar. I’m just a drunk. And if I had my way, if this were about my strength, my desires, I’d be an active drunk. At 10 am, I’d already be thinking about how to plan my day around the afternoon’s drunk, the nap, and then the evening’s drunk.
I’m an alcoholic. But I haven’t drunk today. It’s been a few days in a row now. I never want to forget what I am. I never want to forget where I was. How I got there, and then what got me from there to here.