News

March Madness

I married a basketball nut. This is her most wonderful time of the year.

I enjoy sports, too, but for deeper and more practical reasons. I’ve long considered football (the American variety) a metaphor for life. For example, Nick Saban’s “process” is one of my key clinical tools:

“Don’t think about winning the SEC Championship. Don’t think about the national championship. Think about what you needed to do in this drill, on this play, in this moment. That’s the process: Let’s think about what we can do today, the task at hand.”1

The Washington Post recently published a long profile on Kim Mulkey, the women’s basketball coach at LSU. She’s unquestionably great in objective terms—four national championships—however, this paragraph stopped me cold:

“As a head coach, you’re responsible for so many people; you’re taking on a role that leaves a very lasting impression,” a former Baylor player says. “You might be able to win us a championship, but are people going to want to come back and see you?”

That’s the side of coaches (and leaders more generally) that people seldom see. Nobody writes stories about that.

This image has an empty alt attribute; its file name is three_peat.jpeg
Credit: North Park University; Chicago, Ill.

But I’ve seen it. Joan’s a basketball nut because her father, Dan McCarrell, was a college basketball coach. Former players and assistant coaches are always calling “Mac” on the phone to reminisce about past triumphs—but also to thank him for the springboard into later non-athletic successes.

The trophy case and championship rings are nice, but there are bigger prizes. ✸

  1. Ryan Holiday. The Obstacle Is the Way. New York: Portfolio / Penguin, 2014, p. 87

Three-Peat

It’s that time of year when heavy boxes (nine pounds) arrive with the fruits of last season’s labor. The 76th (!!) edition of Conn’s Current Therapy is now in print, and with it my chapter on alcohol use disorder.1 I’ve been the chapter author since 2022.

Many thanks to my old partner, Tim Scanlan, M.D., for passing my name along to the editorial team at Elsevier. And also to my editors Rick Kellerman, M.D., and Kevin Travers.

I’ve been invited back for 2025. I plan to add a section on ambulatory withdrawal management.2 I’ve also been mulling over whether risks related to alcohol truly “start from the first drop.”3 Finally, the updated edition of The ASAM Criteria, which appeared in late 2023, likely requires brief mention. ✸

  1. Page 841ff ↩︎
  2. J Addict Med 2020;14(3S Suppl 1):1-72 (PMID: 32511109) ↩︎
  3. World Health Organization ↩︎

Rural Medicine

I attended the University of Minnesota Duluth (UMD) for my first two years of medical school. Its mission is to educate physicians dedicated to family medicine, to serve the needs of rural Minnesota and Native American communities.

UMD faculty had mercurial ways to discern whether applicants were truly interested in rural practice. One confided that he often asked, “When was the last time you were on a tractor?”

A related question recently popped into my head: “How do you know you’re practicing rural medicine?” I’d submit that your practice is definitely rural when patients arrive on tractors and you can see a farm from a hospital window.

Front entrance of Osceola Medical Center in western Wisconsin. I saw the patient arrive. For data privacy reasons, I waited until he was out of the frame before snapping this photograph

_
Postscript. Other UMD grads will get this. It took 20-some years, but I’m finally fulfilling something close to the school’s mission. Osceola is right over the Minnesota border. Some of our patients are Minnesotans! I’m still a mental health and addiction guy, but I’m actually doing some family medicine. It’s never too late for you, too! ✸

Neurobiology of Holiday Relapses

Why does your car stop at a red light? Sure, you press the brake, but do you really think about it? For experienced drivers, the answer is no — it just seems to happen on its own.

A vaguely appreciated or unsensed cue (e.g., stoplight) causes a driver to bring their vehicle to a stop. Photo: Ludovic Simon, et al.

This is the miracle of the brain: it can automate processes so you don’t need to consciously think about them. But this is also the challenge of addiction. Unhelpful mental scripts keep executing themselves, even when you sincerely want them to stop.*

What causes the scripts to execute? The Big Book contains various clues that have since been verified by modern science. The biggest drivers are

  • Negative affect
  • Stress
  • Cues

The Big Book famously describes those with addiction as “restless, irritable and discontented.” This is the best description of negative affect that I have ever seen.

Stress occurs when “environmental demands tax or exceed the adaptive capacity of an organism.”

Cues are environmental triggers — “people, places, things” — that have previously been paired with drug use. Sometimes you are consciously aware that cues are present, for example, you notice bottles of wine in a restaurant. But in many cases, they are unsensed. The brain registers the cues but there is no conscious appreciation that they are there.

The vignette in Chapter 3 of the Big Book brings this all together. Jim, the salesman, reported, “I felt irritated” after a dust-up with his boss. (Negative affect) He might have been stressed over a sales goal. He stopped at a roadhouse to grab a sandwich. The place “was familiar for I had been going to it for years.” (Cues) Despite “no intention of drinking” and “no thought of drinking,” Jim inexplicably “ordered a whiskey and poured it into [my] milk.”

What was responsible for this “plain insanity”?

Negative affect, stress and cues.

Why are alcohol and other drugs “cunning, baffling, powerful”?

Because “addictive behaviour appears to involve processes outside of the sufferer’s personal consciousness by which cues are registered and acted upon by evolutionary primitive regions of the brain before consciousness occurs.” Spooky functional imaging studies have shown this to be true.

The holidays often involve negative affect and stress. And there are often a lot of cues, both sensed and unsensed, in holiday environments. This “perfect storm” can initiate a behavior chain that often leads to unintended problem behaviors (alcohol or drug use).

I will be talking with my patients about countermeasures for the next month. ✸

* St. Paul lamented, “I do not understand my own actions. For I do not do what I want, but I do the very thing I hate” (Romans 7:15; NRSV). This gets into the realm of reversal learning, which is part of the neurobiology of addiction.

Remembering Wes Thomsen — 2

I knew Wes Thomsen for the last 7 or 8 years of his life. His recent celebration of life gave me a small sense for the decades prior. And what a life it was!

Toward the end of the service (01:23), someone noted that Wes was a rock star. Not in the current colloquial sense — but member of a band. A soulish song, perfect for the occasion, followed.

I looked for the song on streaming services as soon as I got to my car but couldn’t find it anywhere. An old post on Pegtop led me to Matt Patrick. He graciously e-mailed the track* to me with permission to post it here.


The moon is shining on the waterline
and it makes me think of you.
Venus and Mars all the trees and the stars
make me think about you too.

A GoFundMe for Wes’s family is so close to its goal. Please give generously. ✸

* “I Believe In You” is the final track (11) on Just Us (album).

Addiction Treatment in Jail

I’m happy to be back at the Minnesota Sheriffs’ Association annual Correctional Health Division Conference. This year, I’m presenting on withdrawal management and disease-modifying medications.

Click Image to Launch PowerPoint

Many thanks for Holly Compo and the organizing committee for including me in this event! ✸

Remembering Wes Thomsen

News of Wes Thomsen’s sudden passing reached me Saturday afternoon at a wedding. I found myself struggling with the juxtaposition of beginnings and endings, joy and sadness — and, ultimately, future versus finality.

I’m going to remember Wes in innumerable ways: his ready smile; his unhurried manner; his palpable sense of contentment; his vision and creativity; his deft leadership skills; his deep desire to help those touched by addiction; his amazing portfolio of work at Hazelden Publishing (example here); and so forth.

Wes Thomsen (left) on set at Westminster Presbyterian Church in Minneapolis, Minn., on August 3rd, 2021.

But I will mainly remember Wes as a friend surrounded by lights and cameras who blessed me with amazing conversations. ✸

Kate Gillette created a GoFundMe campaign to benefit Andrea and Margot. Please give generously.

P.S. A lovely memorial service occurred on October 1st. I appreciated the photographs of Wes, hearing the various recollections and tributes, and the remarkable closing song by Pegtop. A recording of the livestream captures most of this. I’m currently trying to find a stream of “I Believe in You,” a track on Just Us.

22

Joan and I got married on September 15th, 2001. I was still a newish family medicine resident and was rounding in a hospital on the morning of 9/11.

Steven Frenz; Dan McCarrell, Jr.; David Frenz; Matt Bergerson; Ashley Brandt | Photo Credit: Joe Treleven

Jamie Santilli, our attending physician, told the residents to take some time to process what was occurring. I remember her tremendous humanitarianism when the anniversary of 9/11 rolls around each year.

Our wedding and surrounding events happened as scheduled. Tom Johnson, a retired pitcher for the Minnesota Twins, officiated. Sara Renner made wonderful music. We were missing a bridesmaid and a few guests — but many converted cancelled flights into roadtrips to Minneapolis.

We honeymooned in Ely instead of Italy. Joan’s Jetta, ever trouble, dropped its muffler on our drive north. We burned some wedding cash at a repair shop as we passed through Duluth.

I still have my wedding coat and tie and wear them a few times a year — generally to weddings! ✸

Symbols — No. 1

For a few years, our family attended a Christian church that met in a Jewish community center. I’d often get bored with the service and hung out in its art gallery instead.

And so it was that I was playing hooky on February 15th, 2015. I came upon a placard that encouraged me to take a key out of a large jar nearby.

I encourage you to do the same — find a key and “think about what you would unlock in your your personal life to ensure a better future.” Add it to your key chain or maybe keep it on your person as a constant reminder of your “truest self.” ✸

I regret that I didn’t capture the artist’s name at the time. I believe that it was either Aviva Klein (and here) or the Jewish Family and Children’s Service of Minneapolis. I’m happy to update this post if someone provides me with better attribution.

Carl G. Jung. Man and His Symbols. New York: Anchor Press, 1964