Sunday, October 15, 2006

PFDs, Binge Drinking and Therapeutic Court

Wassilie is a small man, less than 135 pounds, in his mid thirties. He is married, has three children with his wife, and three other children with his former girlfriend. When he is sober, which is most of the time, he is a hard-working man who fishes and hunts to provide for his family and intermittently holds short-term jobs sweeping up the village school or stocking grocery shelves to bring in a few dollars.

The problem is that Wassilie is a binge drinker. Every two or three months the cravings will start and he will hit the bottle hard. For several days to two weeks, he will drink until he passes out and start again as soon as he wakes up. The cycle will only stop when he runs out of booze and money to buy more. The time between achieving inebriation and passing out may last the better part of a day, during which he is raging around and often quite violent. His wife Agnes takes the children and crosses the river by boat or snowmachine to the smaller village where her parents live to wait out Wassilie’s binge.

“He’s such a good man when he is not drinking,” she tells me. “I love him, and I don’t want to leave him. He’s a good dad to the kids, and he takes care of us. But I just can’t stand this any more.” She had brought the youngest child in to see me for a six-month Well Child Exam. This was in October of last year. Wassilie had been gone for two days; he said he was going to Bethel, and she knew what for. To get drunk.

Wassilie’s last binge was almost exactly one year ago. It was how he spent his PFD check. Every year in October, the State of Alaska issues a check to each resident from the Permanent Fund Division; the money so divided represents the interest made on oil in the previous year. The check that each resident receives can be as little as $300 or as much as $1200. Last year, the PFD checks were about $800, as I recall. A family with eight or ten children receives quite a little nest egg every year; some use it responsibly and some don’t.

Wassilie never touched his children’s PFD checks; he always gave them to his wife to buy things the children needed. A few years back, she insisted that he turn over his own as well, and the five checks together were enough to buy them a nearly-new snowmachine. He built a plywood sled to pull behind it, which meant transportation for the whole family.

Most of the villages of the Yukon-Kuskokwim Delta are completely dry; it is illegal to possess alcohol in them. Bethel is “damp”; no alcohol is legally sold here, but it is legal to purchase it elsewhere (like Anchorage) and bring it in. But you must be a Bethel resident to do so; if you live in a village, the bootleggers are your only recourse. Bootlegged alcohol is expensive; a 750 ml bottle of R&R or MD20/20, which sells for less than $10 in Anchorage, goes for $50 in Bethel. Folks like Wassilie have a hard time staying drunk for long; they just can’t afford it.

The big exception is PFD time. $800 will buy a lot of booze, even in Bethel. Last year, Wassilie bought a dozen bottles, holed up at the cheap-and-sleazy Louse-bag motel, and proceeded to get rip-roaring drunk.

By the fifth day he had finished off eight bottles. He was beyond remembering details of anything that had happened. He had a vague sense that some partying had gone on with several other drinkers, and he thought he had probably had sex with one or two women, but he really wasn’t sure. It had happened before. The black eye and the cut on his cheek were evidence that he had fought about something. He didn’t know what.

When Wassilie is drunk and still standing, he tends to vacillate between morose sadness and murderous, unfocused anger. Once he can no longer stand, but before he passes out, the anger usually gives way to crying. He was half way through the ninth bottle on that last binge when the anger became overwhelming and he felt like he had to hit someone or just explode. Maybe his cousin back in the village who had called the Village Public Safety Officer on him that time. When he felt this way, he never knew exactly what he was angry at; any excuse for a target would do. Maybe he would go back to the village that afternoon and beat the guy up. He deserved it.

Wassilie was staggering through the mud near the edge of the river looking for his boat. He had left it near the small boat harbor several days ago when he came in from the village. It had gotten wedged between two other boats, but he managed to free it. And the gas can was still there. He maneuvered the boat out into the slough that leads to the small boat harbor when the motor died. He leaned over the back to unhook the cowling, but he was too drunk to keep his balance. He tumbled right into the river.

He might have drowned if someone hadn’t seen it happen and called the police. He was still mad, but too cold to fight much by the time they hauled him out. He was charged with Driving Under the Influence, and taken to the hospital. Blood alcohol level 0.6. He went to jail.

When he was sober, he went before the judge for sentencing. This was Wassilie’s third DUI in less than five years, once on a snowmachine and twice in a boat. Alaska has a “three strikes” law: the third DUI is a felony and carries a $10,000 fine. A felony means never getting a job with the school district, and places limitations on employment with the state or the hospital. And he knew the judge could put him in jail for a while, in addition to the fine.

He wanted another chance. When the judge offered him the option of attending Therapeutic Court, he knew it was the opportunity to get his act straightened out. He didn’t want a felony on his record, and he did not want to be sent to the penitentiary for two years. He chose Therapeutic Court. As always, when he was sober, he knew that alcohol was ruining his life, his marriage, his relationships with his children. He really wanted to quit drinking; he just did not know how to resist the urges when they came. Because he was sincere about wanting to recover, the District Attorney agreed to reduce his sentence to reckless driving and suspend the fine, once he completed the program successfully.

Therapeutic Court is an 18-month-long program. Clients are required to take daily breath tests, undergo random urine drug screens, attend daily therapy sessions, and take oral naltrexone for the first three to six months in the program. Therapeutic Court requires Directly Observed Therapy for naltrexone compliance, so the clients can’t stop taking it and remain in the program, unless they have a medical provider’s permission. Most clients take it for six months.

Naltrexone has become widely used in alcohol and drug dependence treatment programs. It is an opioid receptor antagonist; it blocks the opioid receptors in the brain. If someone on naltrexone uses drugs or alcohol, they don’t get high from it. Cognitive abilities and motor skills will still be impaired by using; the naltrexone does not change that. It simply eliminates any pleasure from the experience. With time it also seems to help eliminate the cravings to drink.

Because it is blocking opioid receptors, naltrexone reduces the ability of pain medications to relieve pain. When patients on naltrexone have a painful injury, treating their pain can be difficult. They require higher than normal amounts of opioid meds to overcome the blockade caused by naltrexone. If they were to stop the naltrexone, which sensitizes the receptors, they could overdose on the pain meds.

Counselors in the program strongly encourage only the use of anti-inflammatory drugs like Ibuprofen, combined with acetaminophen, for management of all but severe injuries. All too often, they say, giving Therapeutic Court clients any pain meds such as hydrocodone or oxycodone is the first step towards them falling completely off the wagon. The cravings to drink that had been under control with naltrexone come back strong and clients often give in.

Naltrexone has few drug-drug interactions, and generally few side effects. About ten percent of people taking it will feel some mild nausea for the first two to six weeks, but not usually enough to make the drug intolerable. Occasionally it may affect liver enzymes, so those are checked before placing a patient on it, and rechecked about every six months during the course of treatment. Interestingly, many of our chronic alcoholics have pretty normal liver function tests, despite the heavy use of alcohol. The binge pattern, often with long periods of sobriety between binges, is thought to be responsible.

My friend Joan is a counselor for Therapeutic Court. The staff there works closely with the hospital’s behavioral health program; the behavioral health mid-level generally does the intake physicals and prescribes the naltrexone. That position is currently vacant (and being recruited for—anyone interested?); in the interim, Joan asked me if I would be willing to see their clients for these needs. It would mean two or three physicals each month with counseling about the naltrexone use and screening for co-morbid depression and anxiety; and clinic visits for any non-emergent illness or injury complaints the clients might have during the year and a half they are in the program. Particularly important is addressing pain management issues with the client. I agreed to fill in until the new mental health provider comes on board.

Wassilie brought his wife and children in last week for Well Child Exams and flu shots. He wanted one too; “I can’t get flu this winter, you know? Got too much to do.” Agnes smiled at him.

Wassilie has been in the program for almost a year now, and he is doing well. He is proud of his sobriety and his wife is proud of him for doing it. He is still on naltrexone, because he believes it helps him “be strong against the cravings.” It has been six months since he had one, so he thinks at his one-year anniversary he will be able to stop taking it.

He looks so much better than the last time I saw him. His eyes are clear, his skin color looks healthy, and his pride in himself is evident. He makes eye contact with me for more than two seconds. He smiles more. He doesn’t seem defensive when we talk about how his life is going. He recently obtained a Commercial Driver’s License and has gotten a job in Dutch’s department as a sewer truck driver for the City of Bethel. The job pays well, has good benefits, and will require random drug screens to maintain the CDL. He has turned his life around. He has reason to be proud. This year his PFD check will go into a savings account.

Wassillie is a fictionalized composite, not a real person.



Blogger #1 Dinosaur said...

What an inspirational post. The economics of life in Alaska seem as disparate as the weather, at least to us down here in the south (48.)

Monday, October 16, 2006 1:33:00 PM  
Blogger A Bohemian Road Nurse said...

Bless his heart. I hope he makes it.

Monday, October 16, 2006 4:06:00 PM  
Anonymous Ruth said...

This reminds me of the restorative justice programs being developed in our area to deal more effectively with families in elder abuse cases. Fines and jail time are not the answer where complex social situations exist. But it takes people with dedication and determination to make programs, like the one you describe, work well.

Tuesday, October 17, 2006 3:55:00 AM  
Blogger Shinga said...

18 months? That is a tough programme and it must be expensive to administer. Nonetheless, it sounds very worthwhile.

Regards - Shinga

Tuesday, October 17, 2006 2:32:00 PM  
Anonymous Ozziedoc the 4th yr med student said...

Very inspirational. Little question tho, is your blog anonymised? Or retold with permission?

Wednesday, October 18, 2006 2:26:00 AM  
Blogger Dr. A said...

This is a great story. In general, we don't hear enough about the success stories. Thanks for sharing!

Friday, October 20, 2006 1:58:00 AM  
Blogger TheTundraPA said...

Thanks, everyone, for visiting and for commenting.

#1 Dino--economics and everything else is disparate here. It is an interesting place to live.

BRN--I think the odds are good this time. Thanks.

Ruth--I agree. Complex social situations are never solved with simple solutions. I'd love to hear more about the restorative justice programs.

Shinga--It is a tough program, but so far very effective. I'm not sure about the expense.

Oz--See the Legal Disclaimer in the sidebar. Anonymized, fictionalized, compositized.

Thanks, Dr. A. I think success stories are important too. We sure hear enough about the failures.

Friday, October 20, 2006 7:24:00 AM  
Anonymous ozziedoc the 4th yr med student said...

oops....apologies for not looking at your site properly.....hope that you forgive me!!!!

Saturday, October 21, 2006 6:51:00 AM  
Anonymous wolfbaby said...

I love a happy ending.. he does have something to be proud of that is a hard habbit to kick. I hope he continues to do well. This is great!!!

Sunday, October 22, 2006 9:30:00 AM  
Blogger Jill said...

It sounds like the hardest part is over for him. I hope the state can direct more funding into this program. It sounds like it could really help a lot of people.

Monday, October 23, 2006 12:12:00 AM  
Blogger Borneo Breezes said...

Another great story.

Wednesday, October 25, 2006 12:16:00 AM  
Blogger kabri said...

I just found your blog today and reading this post reminded me of an Aleut friend I lost on Kodiak to alcohol many years ago. Lovely lady, good friend & extremely hard worker but the final binge killed her. I've been to Bethel, Aniak, Kip and Kwig, winter and summer, and your blog really takes me back to those times. I miss the tundra! Thank you for the wonderful pictures you paint with your writing!

Thursday, October 04, 2007 10:50:00 AM  

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