Health & Wellness: When “One More” Becomes One Too Many

Substance use in the fire service is nothing new. From nicotine and alcohol to marijuana and painkillers, firefighters use and sometimes abuse substances for a variety of reasons. In this article, we will look specifically at alcohol use, focusing on a central question: Does a firefighter need to be an alcoholic in order to need treatment? A lot of us probably think that, for the non-alcoholic, there is no reason to seek help. Let’s explore that assumption.

What constitutes a problem?

To begin, think about a fellow firefighter who you believe has an alcohol problem. (The notion that we can assume you know at least one firefighter who drinks too much is an indicator of how widespread this issue is.) Do you believe that person is an alcoholic? How would you know? Does it even matter? Is your belief that the person drinks too much a gut feeling? These are all valid questions, and some of them are not easy to answer. But I contend that alcoholism isn’t the only consideration when discussing whether a person should seek help.

The American Psychiatric Association publishes a manual entitled the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In layman’s terms, the DSM-5 lists the criteria required to be diagnosed with basically any mental disorder you can think of. The DSM-5 is routinely used by physicians and behavioral health clinicians for diagnostic and treatment guidance, so we are in good company when we use it as the basis for this discussion.

Interestingly, when it comes to behavioral health and alcohol, the DSM-5 does not limit itself only to alcoholism. In fact, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), the DSM-5 “no longer uses the terms substance abuse and substance dependence, rather it refers to substance use disorders, which are defined as mild, moderate or severe to indicate the level of severity, which is determined by the number of diagnostic criteria met by an individual.”¹ 

What we can infer from this is that a firefighter can have an alcohol problem even though they may not be an alcoholic. Now, firefighters are a skeptical (and often jaded) bunch. There may be a tendency for us to think that changing the name of a disorder from “substance abuse” or “substance dependence” to “substance use disorder” is mere fluff. Or, more specifically, changing “alcohol abuse” or “alcohol dependence” to “alcohol use disorder” (AUD) is a difference of wording but not of meaning. But an examination of the DSM-5 criteria for AUD diagnosis disproves any notion that it is limiting itself to alcoholism.

Figure 1 lists the DSM-5 criteria that are considered when diagnosing AUD. Fortunately for us, we do not have to be behavioral health professionals to utilize this chart. As you read through the chart, give yourself one point for each of the criteria to which you can answer “Yes.”

Maybe your number is “0”; maybe your number is “11.” Regardless of the number, don’t be ashamed of it. Please don’t ignore your result or go back and review the criteria to lower your score out of a fear it’s too high. This is not the time to try and fool yourself. Let’s face your number head on and see where you fall within the AUD diagnostic criteria. Refer to the right side of Figure 1 and locate your number. All you need to do is see where your number falls on the scale, from no AUD to severe AUD. Are you surprised? Many firefighters are. If you are thinking to yourself, “This is scaled unrealistically low. Everyone meets two or three of these criteria!” that says a lot more about firefighters and our culture than it does about the diagnostic criteria of the DSM-5.

Looking at the chart, you should conclude that a score of 0 or 1 is good. Beyond that, however, there is a need for concern. Small alcohol problems become big alcohol problems over time, so don’t minimize a score of 2 or 3 as “no big deal.” Understanding that binge drinking now and then or that drinking and driving on occasion may not constitute alcoholism but can still have a significant and dangerous impact on your or others’ lives is an important realization. And if your score is a 10 or an 11, please do not despair. You are not alone. Many firefighters find themselves on the far end of this chart and seek out recovery. 

Regardless of how you feel about your number, remember that we tend to be biased in favor of ourselves and will want to believe that we know better than the DSM or that the DSM criteria don’t understand our population. That response is normal, but it is nevertheless the inaccurate result of our natural denial mechanism and personal biases—of which the DSM contains none. 

Getting the assistance you need

You may be asking, “So what does all this mean? How can I get help?” Please understand at the outset that if you have a moderate or severe alcohol use disorder, it is critical for you to consider whether you will have withdrawal symptoms. Alcohol withdrawal marks the onset of a complicated process that involves the release of large amounts of epinephrine, serotonin and dopamine, which can cause serious complications. But don’t let those complications keep you from getting sober; these symptoms can be safely managed with medical supervision.

Withdrawal symptoms may include anxiety, visual and auditory hallucinations, convulsions, whole body tremors, nausea, vomiting, insomnia, diaphoresis (profuse sweating), shakiness, convulsions, DTs, hypertension and heart failure.² If you stop drinking and experience any of these symptoms, you must seek medical attention. If you have any doubt whether you will have alcohol withdrawal, consult with a physician to discuss best practices. Your conversation will be confidential and is critical to safe detoxification.

After you have stopped drinking and have any withdrawal symptoms under control, you will be on track to getting sober. There are many programs available to assist with your recovery. I will not advocate for any particular group or model here, but some common programs are inpatient treatment, outpatient treatment, and self-help (or 12-Step) groups like Alcoholics Anonymous. Some people require the use of multiple programs to achieve recovery, and that is perfectly acceptable. What system you decide to use is a very personal decision, but consulting with your physician or a therapist can be useful. Also, employee assistance programs (EAPs) and peer support groups can be wonderful resources to find out what programs are available and respected in your area. 

This may be the most important process of your life, so don’t try to rush through it or to take the easiest route. It may be a long process, so being informed and comfortable with your decisions is crucial. Always remember that you are not alone in this process, and many of our brothers and sisters have been through it. AUD is a common affliction in our population, so please do not ever feel ashamed about it. The road forward is where you should be focused, and you will be travelling it with people who understand what you are experiencing.

Alcohol may not be the only problem

You should also be aware that getting sober may be only half of the equation for recovery. It is common for firefighters to suffer from both AUD and one or more behavioral health disorders. In fact, according to the American Addiction Centers, among the general population, “[t]hose who present with symptoms of a substance abuse or addiction disorder are about twice as likely to also experience symptoms of a mental health disorder as compared to those who do not struggle with drug and alcohol use.”³

When you consider firefighter exposure to potentially traumatic events, sleep deprivation, compassion fatigue, vicarious trauma, burnout, and high rates of PTSD and depression, it should be clear why we see even higher numbers of firefighters suffering from both alcohol and mental health disorders than we see in the public at large.

A person enduring these illnesses at the same time can be clinically described as suffering from a mental health disorder with a co-occurring addiction. Another term for this condition is “dual diagnoses.” It can be difficult, if not impossible, to discern which affliction arose first. Did a mental health problem lead to drinking as a coping mechanism, or did AUD open the door to depression or some other mental illness? For many people, we will never know, but the positive side is that we don’t have to know to get them treatment. 

What we must understand, however, is that both conditions must be treated simultaneously if we expect recovery. After all, it does little good to treat PTSD if the firefighter continues to drink excessively, and it doesn’t help a lot to get someone sober if they continue to suffer from major depression. The chances of relapse are very high if firefighters don’t resolve both aspects of their illnesses. A problem many firefighters face is that they seek help for one problem, but may be unaware of the need to treat the other. In the alternative, a provider may be able to treat one condition but may not understand the symptoms or treatment methodologies of the other illness. So how do we deal with this issue?

Fortunately, there are treatment facilities that specialize in treating patients who have a mental illness with a co-occurring addiction. These treatment centers are often referred to as “dual diagnosis facilities.” Utilizing a dual diagnosis facility is critical for these firefighters to get the care needed for full recovery. This is something about which the firefighter should ask his or her doctor when discussing treatment options. And again, your EAP and/or peer support group are excellent resources that should have lists of dual diagnosis facilities in your area.

Facilities that specialize in only mental health or substance use are wonderful, but when a firefighter is suffering from a dual diagnosis, the need for a dual diagnosis facility cannot be overstated. According to the National Alliance on Mental Illness, the integrated intervention approach utilized by dual diagnosis facilities ensures that the firefighter “receives care for both a specific mental illness and substance abuse. Because there are many ways in which a dual diagnosis may occur, treatment will not be the same for everyone.”⁴ 

If you are in doubt as to which type of facility you need, I encourage you to get screened by a dual diagnosis facility first. If you are not suffering from a dual diagnosis, they will tell you so and can refer you to an appropriate facility. The dangers of misdiagnosing a mental illness with a co-occurring addiction are simply too high to risk not starting at a dual diagnosis facility if you are unsure.

Better tomorrows begin today

The road to recovery can be complex, and it will probably not be an overnight success. But with personal honesty and a resolve to get sober, you can live a better, more fulfilling life. Because of the nature of our work, we are at a higher risk of developing mental health and alcohol use disorders. That awareness is a large part of the battle to recognizing when we need to reach out for help.

Regardless of how you decide to ask for help, be aware that a dual diagnosis facility may be needed. Fortunately for us, there are actually dual diagnosis facilities in North America that specialize in treating firefighters. And even if you can’t access a facility specializing in the fire service, there are plenty of other amazing facilities waiting for the chance to help you recover.

I will leave you with the following if you are considering the need for help: You should not feel embarrassed. You deserve to get your life back. You are not alone.

References

1. Substance Abuse and Mental Health Services Administration. “Substance Use Disorders” October 27, 2015. Retrieved from samhsa.gov/disorders/substance-use.

2. Promises Treatment Centers. “How to Detox from Alcohol: Is Going Cold Turkey a Bad Idea?” Retrieved from promises.com/resources/detox-information/detox-alcohol-going-cold-turkey-bad-idea.

3. American Addiction Centers. “Co-Occurring Disorders Treatment Guide.” October 2017. Retrieved from americanaddictioncenters.org/co-occurring-disorders.

4. National Alliance on Mental Illness. “Dual Diagnosis.” 2017. Retrieved from nami.org/Learn-More/Mental-Health-Conditions/Related-Conditions/Dual-Diagnosis.