At her first visit, still lightly jaundiced, Jennie wanted to talk about a liver transplant.
I told her that she had to be sober for six months before they would consider putting her on the list. She told me proudly that she had been sober for three weeks.
“How are you doing without alcohol?”
“Going without alcohol would be very hard for me,” she said, “I have just one glass of wine each night at dinner.” My mouth dropped open.
“I thought you said you were sober.”
“I am! One glass is not enough to get drunk on for me!”
She was surprised to learn that she had to quit drinking altogether. “This is the first time anyone has told me that!” And I could not imagine that in all those emergency department visits, no one had ever told her she had to stop drinking, but I told her now. “Not a single drop. None. Not even on special occasions.”
That night, over dinner with my husband, I wondered how she had thought ‘sober’ included one drink nightly.
Again, I was shocked when my husband said, “Sober doesn’t mean no alcohol. Sober just means not being affected by alcohol. You can have a little alcohol and still be sober. You don’t have to blow zero to pass a sobriety test.”
I was shocked again later when I could not find a general dictionary that defined sober as not drinking any alcohol, but this is the medical definition. It is what we mean when we tell someone with alcoholic liver disease to get sober: do not drink ever again.
It has happened twice in my career that people who were frequent flyers for alcoholic liver disease stopped drinking simply because I told them to. Both patients said, “no one ever told me I had to quit,” and I had my doubts but did not investigate further.
Perhaps the other patients were told their lives depended upon their being sober. They never got drunk again and thought they were doing exactly what the doctors had told them. We doctors would be so frustrated every time they came in with an alcohol-related problem. “If only they would stop drinking!” we would think to ourselves. “You have to get sober!” we would tell them. We knew what sober meant: no alcohol. They knew what sober meant: no drunkenness. They would think to themselves, “I am sober!” but be too respectful to say it.
Of course, all things being equal, an alcoholic is going to listen for a message that tells him or her to keep drinking, and a busy doctor who is certain the patient has been told to stop drinking on all of their last dozen visits is not going to take the time to say “stop drinking” more than one way. And all parties are so sure they know what the words mean that they do not ask for clarification. What might happen if the doctors were curious about: Why are you not following my advice? Or the patients about: Why is your advice not working?
In the wrong setting, an amount of alcohol so small it does not impair one’s thinking can be the difference between life and death. The same amount of difference in meaning can have the same result.
It’s not glamorous, but Jennie’s life depends on her knowing what sober means.
Mary Braun is an internal medicine physician.