August 22, 2004
Joe Six Pack in the News
Keith Emerich has bounced in and out of the news in recent weeks. His physician contacted the Pennsylvania Department of Transportation (PennDOT) to identify Emerich as having a condition that could impair his ability to drive safely. Radley Balko has also tracked the story.
The condition which the law requires the doctor to report is alcohol misuse — which Pennsylvania legal code doesn’t define any further — not addiction or dependence.
Let’s take a look at the sequence of events, how Emerich stacks up against the criteria for alcoholism, then sensible drinking, treatment options, and finally ethical perspectives.
- 1960s: PA passes a law requiring doctors to report patients with impairments that could compromise their ability to drive safely such as seizure disorders and Alzheimer’s; licenses are recalled indefinitely until the driver proves competency to drive.
- 1976: PA legislature creates the Medical Advisory Board to decide which conditions warrant license suspension.
- February 2004: Emerich seeks medical care for an irregular heartbeat. Asked about his drinking, he says 6-10 beers nightly is typical. Alcohol is identified as damaging his heart, and he is advised to cut back.
- 01-April: Emerich receives a notice from PennDOT saying that his driver’s license will be recalled in a month for medical reasons related to substance abuse. A physician has followed PennDOT instructions (20K PDF), which encourage the doc to report and protect him/her from being sued.
- 06-May: Emerich’s license is recalled by the PennDOT.
- July: The PennDOT Medical Advisory Board reviews criteria for license suspension; no changes made.
- 29-July: Emerich appears at hearing to appeal the suspension. “It’s the law that’s wrong,” not his doctor, he says.
- 18-August: County Judge Bradford Charles rules that PennDOT should not suspend driving privileges indefinitely, but citing doubt about Emerich’s claim to have dramatically reduced his drinking, orders him to install an ignition interlock (a $1,100 annual expense) if he wishes to resume driving.
Does Emerich have alcohol dependence (alcoholism)?
Philly.com, 20-Aug: Psychiatrist Charles O’Brien, a University of Pennsylvania addiction-treatment expert and head of mental health research at the Philadelphia Veterans Medical Center. “Anyone who has 10 beers at a sitting is, by definition, an alcoholic.”
That definition doesn’t exactly square with the DSM-IV criteria for alcohol abuse and dependence. The abuse criteria looks for continued use despite failure to meet obligations, causing physical hazards, legal or interpersonal problems. The threshold for dependence is any of that plus high tolerance, withdrawal symptoms, or inability to cut back despite knowing the consequences. But, no negative impacts on his job or family relationships have been reported from his drinking, and on July 29th:
Philly.com, 08-Aug: At the hearing, he said his Bud habit was all but gone, reduced to a six-pack a week, tops.
“I’m not saying that just to get my license back,” he said afterward. “It’s for my health.”
Philly.com, 08-Aug: At six feet tall, 250 pounds, he is a big enough man to drink six Buds in two hours and keep his blood-alcohol level within the legal limit of 0.08 percent, by the National Highway Traffic Safety Administration’s formula.
I’ve found no indications that his doctor told him specifically to quit, or that a clinical evaluation has resulted in a diagnosis; he reports that he has cut back significantly without a lot of distress, and seems to be taking personal responsibility for improving his health.
The judge didn’t see it that way, and it’s not clear what evidence he was relying on when he made these comments:
Philly.com, 18-Aug: “If Emerich’s alcohol addiction had progressed to the point where he could not stop drinking even though it was killing him, how could we reasonably expect Emerich to forgo alcohol simply to ensure safe driving?” wrote Charles in his ruling.
LDNews.com 19-Aug: The judge also wrote: “… the abyss of Emerich’s alcoholism was so cavernous that he would and/or could not moderate his alcohol consumption so that he could safely drive.”
Was he drinking sensibly?
Not by any of the standard yardsticks. He was somewhere in the range of 40-70 drinks weekly, pretty similar to where I was at in 2000. Among his U.S. peers, 6-10 beers per day put him in with a lot of men who drink, but only a few at that daily level:
|Within this group|
|25-44 y/o men||76.8%||At least once monthly||CDC |
|45-54 y/o men||70.1%|
|Adult men||8.4%||More than 2 drinks daily|
|25-44 y/o male drinkers||49.7%||5 or more drinks on at least one day monthly|
|45-54 y/o male drinkers||38.0%|
|35-54 y/o male drinkers||33.3%||5 or more drinks on at least one day monthly||JAMA |
|Adult men who average 2 or fewer drinks daily||30.1%||5+ on an average of 9.5 days annually|
|Adult men averaging over 2 drinks daily||88.2%||5+ on an average of 113.6 days annually|
So, he was well into the 90th percentile in drinking quantity and frequency, not something that many folks can sustain for decades and yet remain healthy. His drinking was starting to cause him problems, as mine did, and continuing with the same pattern was likely to accelerate the consequences.
In one study, a small group of 40-year-old men had an average of 4 drinks daily for 20 years without consequences, while their peers who averaged 5 or more daily generally ran into problems. That evidence doesn’t tell us that 28 drinks weekly is wise or healthy generally (there’s evidence to the contrary), but it suggests that some guys in Emerich’s age range have sustained that pattern for decades without major consequences.
It’s not unusual for us to find ourselves in places like this in our 40s. It’s also fairly common for us to mature out of heavy or addictive drinking patterns — most often without professional treatment — as described by Dr. Stanton Peele.
Is some sort of treatment or support warranted?
Keith Emerich sounds like he’s in good shape to answer that question himself.
If I were him, I’d be getting follow-up care on the irregular heartbeat that started this in February. I’d want to keep track of whether the heart issue is stable and have my doc tell me about the risks and/or benefits of continuing to drink moderately.
Sometimes folks get shocked into abrupt behavior changes, and maybe the heart problem was everything he needed to accomplish that. More often, we end up working through stages of change, so it wouldn’t surprise me if cutting back his drinking has been more of a struggle than he’s mentioned publicly. Sometimes a little bit of the right help moves the change process along more quickly.
If his heart problems were to escalate, his doc is sure to ramp up treatment and/or get specialists involved. The drinking can be handled the same way — if self-care ends up not getting the job done, it would be worth his while to try some sort of peer support or get professional care.
Bottom line, assessment and choices of treatment reside with him and the experts he chooses to consult.
Is treatment available that would fit him?
CentreDaily.com, 14-July: “They want me to go to counseling to prove that I’m OK,” Emerich said. “I tried to go to a place … and they wanted $250 for a three-month program.”
Hmmmm… harm reduction therapy can be done in pieces much shorter than 3 months. Services offered by folks like Tamara Grams in St. Paul and the RRCI in Cincinnati (from Friday’s article) aren’t blocked off that way, either. Perhaps he was talking to folks oriented to doing 12-step work.
Thus far Emerich sounds determined and conscious, not much given to powerlessness, but perhaps still working through some ambivalence. Long-term abstinence could still be on the horizon as a good option, but chances are good that A.A. is either not a good fit, or not a good fit yet.
The chances are also pretty good that somebody like Psychiatrist Charles O’Brien, quoted above, would not hold Emerich’s attention or respect for long. Dr. O’Brien’s complete thoughts might be more nuanced, but the quote used by Philly.com suggests that he’s working from a broader disease model than the DSM-IV that would require clients with substance abuse to admit denial and would discount the evidence that drinking problems often don’t lead to addiction.
Finding client-centered care that meets us where we’re at is still a challenge in most areas. A few cursory web searches for alternatives to 12-step support in Emerich’s area didn’t produce anything promising.
What about the ethical issues?
The guy did nothing that’s against the law. Yet if he wants to drive, he’s now required to pay an extra $1,100 … for the privilege.
The case also puts a chill on doctor-patient privilege. What Emerich admitted to — drinking — isn’t even illegal. Guess if you’re a Pennsylvanian, you’ll now need to think twice before telling your doctor everything he needs to know — even if that means an inaccurate diagnosis.
For many doctors, the crux of the reporting dilemma is maintaining trust with patients.
David Axelrod, an internal medicine doctor at Thomas Jefferson University, confronted that quandary yesterday when a patient who had read about Emerich refused to answer a routine question about alcohol consumption.
“He did not want to answer that question at all because of the fear that what he says can be used against him,” Axelrod said. “I didn’t press it.”
Penalizing an innocent person based on the “likelihood” he will commit an offense DUI, in this case is a slippery slope. … There is language in Charles’ opinion that suggests a strong bias against alcohol use of any kind. … One must wonder whether the judge thinks anybody who consumes alcohol is ever fit to drive…
“Likelihood” is indeed a slippery slope. In this case, it led to a presumption of future guilt. We find that troubling.
The odds just got shorter that the attending doctor will be aware of his client’s fondness for a cold one. And that could be a dangerous mix.
Edmund G. Howe calls it “a crapshoot.”
“What one doc considers abuse might not seem as severe to another doc,” said the editor-in-chief of the Journal of Clinical Ethics and a psychiatry professor at the Uniformed Services University at Bethesda, the U.S. military’s medical school.
“I tend to think docs can’t do two jobs and do them both well,” Howe said. “They can’t be adjuncts to the police force and at the same time form trusting relationships with patients.”
What a joke. In most states they even let you drive after you get a couple of DWI’s. What’s with Pennsylvania? This is akin to requiring child-abuse victims to register as sex offenders because they might become pedophiles themselves.
When I get insurance again, I will probably have to get a new doctor. I probably will not tell him off my alcoholism, because I feel that I do not get the same level of care as other, non-addicts. For instance, I get no help with pain, cough or anxiety. My current doctor doesn't want to give me "drugs" because I am an admitted alcoholic.
I broke my butt bone falling once (no jokes here) and recieved no pain medication for a broken bone. I have chronic bronchitis, and recieve no cough medicine for it (because it contains codeine.) I have terrible panic attacks, and recieve no medication for that. I don't even bother to ask. Alcohol is my drug of choice, not pills. But my doctor won't hear that.
Don't know why I brought this up...it's just one more reason to lie to my doctor.
23-Aug-2004 03:15 PM
Getting good health care is a very valid, reasonable concern, Faith. Dr. DeLuca just posted the article When Good Intentions Hurt, which talks about the barriers some folks who have never had substance use/abuse issues have had trouble getting effective pain relief.
With drinking problems, the challenges can include:
- Being referred to peer support groups led by well-meaning laypeople when professional care is needed
- Being refused care or treatment for co-occuring issues until after alcohol-related issues are addressed
- Being referred to care for dependence (alcoholism) when a professional assessment would have revealed abuse (problem drinking) and often co-occuring issues
- Not being heard or believed because of uncritical assumptions about clients being in denial.
Here's an alternative for you to think about when it comes time to doctor-shop, Faith: Call around and ask the questions ahead of time. If it was diabetes instead of alcoholism, you'd be asking the docs about their expertise, so you could do the same:
- What percentage of your patients are recovering alcoholics?
- Are you familiar with some of the latest research in alcohol-related care? How are you applying it?
- How experienced are you in helping patients who happen to be alcoholics manage pain?
- What's your approach to helping patients who need support with relapse prevention?
- Have you prescribed naltrexone for any of your patients? Did you find it helpful?
My point is not that you'd ever need or want to try the different options, but if you find somebody who is determined to serve their alcoholic clients well, they're going to know about these things.
And, of course, you deserve nothing less than effective, evidence-based health care from an expert who is willing to get to know you and tailor your care to where you're at.
23-Aug-2004 07:52 PM
This is the sort of neo-prohibitionist hysteria that really gets my dander up. That MD ought to be ashamed of him or herself, and the state of PA ought to be even more ashamed of passing such a broad, relationship-destroying tattletale law.
You *don't* take away someone's license when they have done nothing wrong. The last I heard, getting bombed in your living room is not illegal. If he is a habitual drunk driver, then by all means yank the license. But that's not what's going on here.
I guess they'd better post the Miranda warning conspicuously at every doctor's office. I will certainly make sure to protect myself, in future, by refusing to answer any drinking-related questions on the grounds that it may be used against me.
Although the disease model is not (AFAICS) gaining too much ground here in the UK, the anti-drinking sentiment surely is. "Unhealthy" and "binge" drinking keep getting defined ever downward...while most Brits simply keep on drinking as much as they always have, thank the gods.
24-Aug-2004 09:57 AM
Radley Balko offered additional insight about the Keith Emerich case on Sept. 4.
Balko quotes extensively from his chat about the case with a representative from the Pennsylvania Medical Society.
12-Sep-2004 12:12 AM
Reading Keith Emerich's case, you would think the ACLU would be all over this one. Unfortunately, they seem to stear clear of any confrontation with MADD or The State when it comes to the plethora of Constitutional violations involving alcohol and drinking. Hopefully a hot shot pro-bono lawyer will help Mr. Emerich appeal the judgement against him.
15-Sep-2004 12:49 PM