There are many pressures to quit medicine, but for those prone to substance use, it can be a leap from the frying pan to the fire.

Lately, I’ve noticed a lot of us talking about early retirement. This may be due to post-covid fatigue or Medicare policy and funding frustrations or both.

The end of the grind would surely be wonderful. But be careful what you wish for. Retirement can be a major existential crisis.

The good news is that there is a certain spiritual alchemy that occurs whenever an existential crisis is successfully overcome. The liberal arts become lyrical in this space. In the 1991 movie Doctor, William Hurt plays the role of surgeon Jack McKee. Jack is emotionally disconnected from everyone, including patients and family. Then he develops a life-threatening illness causing him to turn into a human. Lucky ones have multiple such transformations, increasing their humanity.

I went to rehab recently. I felt the need for a spiritual retreat. My indoor weather vane was swirling alarmingly. You see, I’m heading into retirement, or rather, I’m retiring for my next gig, and I wanted to be in the best shape for this makeover, possibly my last. I had had previous experience with a similar shrine about 30 years ago, and had benefited greatly from a master class on self-enlightenment, or more specifically, self-enlightenment of the subconscious. Carl Jung mused: “Until you make the unconscious conscious, it will rule your life and you will call it fate.”

This time, I felt like a bit of an impostor. In the years between stints in rehab, I enjoyed over a decade of sobriety before I started drinking in moderation again. Sometimes a little more than expected. By comparison, in Queensland, according to its Alcohol and Other Drugs Plan, one in three adults in the general population (1.2 million people) exceed monthly risky drinking on a single occasion.

When checking in, I was asked how long it had been since my last drink. I honestly answered six weeks. Were there any other medications of concern? Yes, cannabis. When was the last time you used? Over 30 years ago. But I knew that many resumed an unhealthy relationship with substances upon retirement.

For context, half a life ago, fate had me trying to mix together perfectionism, an unhealthy work ethic, emotional hypersensitivity, vicarious workplace trauma, stoic bravado, backlash of grief at my mother’s preventable death and sleep deprivation. I had sailed in a perfect storm and had given way under the allostatic load. I had also had a rather rocky relationship with alcohol and using it as medicine didn’t help.

My relationship with alcohol started in college. I don’t know if the prevalence rates are the same today, but in the mid-1970s half of the student cohort had an unhealthy relationship with alcohol. Medical school students were no exception. Plus we were fed a regular dose of the TV series MASH POTATOES*. This was our informal curriculum in medical professionalism. Surgeons Benjamin “Hawkeye” Pierce and “Trapper” John McIntyre were our role models. Work hard and party hard. Those in my social sphere did both.

My thoughts today are as follows. Our beliefs are usually based on our values, which in turn frame our behavior. In Australia, for example, there is a national belief that after a hard week’s work we are entitled to a ‘party’. A party is neurologically equivalent to inducing a dopamine dump. In the “genteel” society that would be sought through alcohol. Downtown (or downtown) which could be via cocaine, cannabis, prescription opioids, etc. In other words, cultural conditioning based on our very human need to appease ourselves. And in the beginning, alcohol and other drugs are a surefire way to satisfy our subconscious dopamine pig.

Now, I am fully aware that the human brain is an inference machine. So maybe I’m re-adapting time-corrupted facts, but… the very first time I got “really high” on an alcoholic drink, I just loved it. It was for me an immense inner creative bliss that offered an almost sacramental vision, the likes of which I had never experienced before. But why was it so?

I guess it’s because I was transported to an extremely comfortable and gripping place, much like the white rabbit hole in Alice in Wonderland. It sharpened my curiosity and imagination. As far back as I can remember, I have ardently enjoyed creative daydreaming. The feeling was like that, only taken to a whole new level. What followed was many years of trying to replicate that. How was I to know it was a one-time, never-to-be-repeated “gift”? Too bad it’s an easy spiritual shortcut that turns into a dead end. For me, the alcohol ROI had turned red. For this reason, all those years ago and on the advice of my psychiatrist, I started taking real antidepressants and stopped drinking alcohol.

Inspired by a new curiosity and search for meaning, I embarked on a new career path in addiction medicine. On this new path, my patients have taught me that what some call addiction is simply the opposite of connection. They also taught me a lot about humanity and transformation.

Enough of this detour, let’s go back to the retreat.

As I pointed out at the beginning of this article, retirement is a major transformation. It’s a time for disconnecting, celebrating, and making new connections. My recent concern was that this potential stressor, i.e. existential crisis, might unleash the wine witch or the dopaminergic pig that I had kept at bay while continuing to practice. What might be the consequences when every night is a Friday night? As stated earlier, it was precisely because of these concerns that I enrolled in rehab. A preventative measure if you will. Like having the Hilux checked before a desert expedition.

Dame Clare Gerada, President of the Royal College of General Practitioners who has a professional interest in mental health and addiction, gave a presentation at the International Society of Addiction Medicine conference in Malta last month, at which I attended. According to the author of Under the white coat: doctors, their minds and their mental health, the prevalence rates of substance use disorders among physicians today (as always) are difficult to pin down. However, its best bet is between 10-15% of the profession with a confidence interval of 5-30%. After all, medicine is a tough master and is intellectually, physically and emotionally demanding. Those who have an unhealthy relationship with alcohol are out of sight among us because they keep performing. Most are very disciplined and likely able to “stay in control” while working.

I suspect the nature of this lid is complex. There was a joke that said “you’re only an alcoholic when you drink more than your doctor”. After all, a doctor would surely know when to get help. But do they? Stigma within the profession is still prevalent due to the prevalence of a humanistic view that makes a binary distinction between rational, volitional individuals and compulsive substance users. You are or are not an alcoholic. But where is the line? Some argue that CIM or DSM categorizations are themselves a spectrum and that their primary purpose is to inventory human conditions for billing or research purposes. But that goal recedes in the real world. That’s why I try to avoid the terms “alcoholism” and AUD in favor of the term unhealthy relationship.

The post-humanist view sees individuals as coexisting in a web of contingent and dynamic relationships. This ethnographic interpretation raises the question of whether the condition is a disease at all. If so, it is abnormal. It has a major social network dimension and requires therapy for family and loved ones to optimize outcomes. What other diseases have inspired philosophers, theologians, scholars and sociologists as much as doctors and neuroscientists? The WHO public health gurus even chimed in by describing alcohol as a toxic substance. According to this definition, everyone who consumes alcohol has an unhealthy relationship with it. But let’s not be stunning.

As I was leaving my spiritual retreat, my psychiatrist casually mentioned that it was much more common to admit doctors who were 18 months or more from retirement. He was happy that I came while I was still “good”. He, too, alluded to studies which have shown that retirement leads to increased alcohol consumption and that alcoholism can progress rapidly in this age group.

I hope we will all stay present and connected at the retreat. An unhealthy relationship with alcohol can be undone. Alcohol use disorder, or call it what you will, is a life-threatening but also treatable disease.

As doctors, my generation, the baby boomers, worked and partied hard. Once the work is done, will the party continue and could it spiral out of control?

Associate Professor Kees Nydam has served as an emergency physician and director of emergencies at various times in Wollongong, Campbeltown and Bundaberg. He continues to work as a senior addiction medicine specialist and teaches medical students attending the rural clinical school at the University of Queensland. He is also a poet and songwriter.

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