In honor of Alcohol Awareness Month
April is Alcohol Awareness Month, a time often filled with statistics, campaigns, and reminders to “seek help.” Those things matter. But sometimes numbers can flatten what addiction really is: not an abstract diagnosis, not a public health slogan, but actual people – brilliant, maddening, creative, wounded, funny, complicated people.
There are patients you never forget because they frighten you.
Patients you never forget because they teach you something profound.
And then there are patients you never forget because you are never entirely certain whether they are delusional, secretly important, or simply way better at improvisation than you.
Frank belonged to the third category.
He was thirty-something, handsome in a weathered sort of way, and chronically serious. He carried himself with the grave posture of a man perpetually late to a war room that might or might not exist, the kind of war room that required wearing sunglasses indoors.
Frank struggled with alcohol use disorder and bipolar disorder, though he discussed those diagnoses with roughly the same enthusiasm one reserves for parking tickets and dentist appointments. He didn’t have the time or patience for such health inconveniences. He preferred to focus on larger matters.
At various appointments, he informed me, always solemnly, in a hushed, serious whisper, that he was currently employed by the FBI, formerly contracted with the CIA, quietly writing a best-selling novel, developing a multi-million-dollar running shoe company, and, in his spare time, an internationally known rapper whose anonymity was necessary for national security reasons.
He would say these things with such quiet conviction that I would occasionally experience a flicker of self-doubt.
Was I underinformed?
Perhaps the CIA at Quantico did recruit heavily from the surrounding suburbs of Northern Virginia, where we lived. Maybe Jay-Z really had entered the sneaker space with an anonymous cofounder. Medicine teaches humility, and occasionally gullibility.
Frank always arrived on time. He dressed neatly. He sat upright. He spoke in the tone of a man briefing Congress.
On one memorable afternoon, he arrived carrying what appeared to be either a tactical surveillance device or a discontinued attachment from a 1997 Dustbuster. It was a long black rod with a blinking red light near the tip and enough unnecessary buttons to inspire curiosity, but not confidence. Before sitting down, Frank began slowly sweeping it around the exam room perimeter with grave concentration, across the diplomas, over the ficus, beneath the side table, and lingering suspiciously near my framed board certification as though both arrogance and hidden transmitters often nested behind credentials.
“Frank,” I said slowly, “what exactly are you doing?”
Without looking at me, he snapped one finger into the air, placed the other hand dramatically over his lips, and hissed:
“Hush.”
Then he leaned toward me and mouthed silently, with the urgency of a man disarming a nuclear device:
Scanning for bugs. Hot mics.
He then pointed the blinking wand toward the tissue box, frowned deeply, and gave it a second pass. Narrowing his eyes, he picked up the unassuming cardboard box, turned it over in his left hand, and poked at the bottom a few times before carefully placing it back on my office desk.
I sat motionless in my rolling chair, trying to project calm while privately wondering whether this qualified for a higher billing complexity CPT code.
After several tense moments, he nodded once.
“We’re clean.”
Only then did he sit down.
“How have you been?” I asked, as though any normal version of the appointment remained possible.
He nodded once.
“Busy.”
“With what?”
He looked cautiously around the room before whispering:
“A new assignment.”
I learned not to interrupt. It only slowed the briefing.
Sometimes the assignment involved dismantling a cyber-threat. Sometimes it involved negotiating a footwear merger. Sometimes it involved finishing chapter seventeen of the novel that would “change American literature permanently.”
I got an A minus in my college creative writing class, so I was in no position to challenge anyone’s literary confidence. But bipolar disorder, for all the devastation it can cause, has long been associated with heightened creativity in some individuals, particularly during milder hypomanic states, when energy rises, sleep feels optional, ideas multiply, confidence swells, and the mind begins speed-dating itself. Studies have found much higher rates of bipolar spectrum traits among writers, artists, and performers than in the general population.⁵
What Frank did consistently care about, more than lithium, therapy, abstinence plans, or the concept of reality itself, was gabapentin.
Not gabapentin, exactly.
“Gaba.”
He spoke of it with the tenderness others reserve for first loves or golden retrievers.
“Doc, I’m good on most things,” he’d say, “but I need my Gaba.”
Gabapentin has some evidence as an adjunctive treatment in alcohol use disorder, particularly for anxiety, insomnia, cravings, and mild withdrawal symptoms, though it is hardly a magic bullet.¹ Frank, however, regarded it as the cornerstone of both neuroscience and national defense.
Months passed. Frank seemed more stable. He was only consuming alcohol on “non-mission-critical days.”
Then came the CIA incident.
One afternoon, clinic staff transferred me a call.
The voice on the line was calm, official, and deeply tired. The sort of voice produced only by military officers, ICU nurses, teachers, and men with at least three ex-wives.
“Doctor?” he said. “I’m calling from Langley CIA security.”
Now, there are sentences that instantly sharpen the senses.
This was one of them.
My entire body stiffened. My mind raced. Had I accidentally e-prescribed trazodone into a restricted database? Was my student loan balance now considered suspicious foreign leverage? Had my browsing history of “best throw pillows for screened porch,” “weatherproof chaise lounges under $800,” and “can a pergola be both tasteful and sexy” triggered some kind of lifestyle-based national security inquiry? I knew I should have used incognito mode for browsing.
The guard continued.
“We have one of your patients here.”
Of course we did.
Apparently, Frank had arrived at headquarters for what he described as “his mission.” He was insistent, highly confident, and carrying no credentials other than charisma and momentum.
The guard, to his everlasting credit, had chosen compassion over confrontation.
“I thought it best,” he said evenly, “to reassign him to the hospital.”
Reassign him to the hospital.
It was the most elegant euphemism for involuntary psychiatric evaluation I have ever heard. This public servant deserved a medal, or at minimum, the rest of the week off.
When Frank returned for follow-up, I approached the topic gently.
“I heard there was some confusion at the agency.”
He gave me a patient smile, the kind one gives a woman who clearly has no security clearance.
“No confusion.”
He leaned in slightly.
“My handler redirected me.”
“Your handler?”
“The bodyguard.”
I nodded, pretending this clarified matters rather than expanding them.
“Too much heat on the first mission,” he said. “I was redeployed.”
Naturally.
Patients with bipolar disorder can experience grandiosity, decreased need for sleep, inflated self-esteem, and psychotic features during manic episodes.² Alcohol use disorder often worsens mood instability, impairs judgment, and increases recurrence risk.³ What textbooks do not adequately capture is how mania can arrive dressed as confidence, charm, and a suspiciously excellent backstory.
I would spend entire appointments with Frank attempting to steer us toward mood stabilizers, recurrence prevention, liver enzymes, and sleep hygiene, while he updated me on covert operations and athletic apparel.
“Are you drinking?” I’d ask.
“Not on mission days.”
“Are you sleeping?”
“Operationally.”
“Any suicidal thoughts?”
“Classified.”
I would jot these responses into the medical record with the solemnity of a person documenting nonsense for legal reasons.
And yet beneath the absurdity was something achingly familiar: a bright, intelligent man whose mind periodically betrayed him, whose alcohol use complicated everything, and whose dignity remained oddly intact even when reality did not.
The years passed. Care transferred. Systems changed. My role changed. I accumulated more titles, more responsibilities, more wrinkles, and two adorable children.
Then one day, I received a call from the addiction physician currently treating Frank.
Frank had been found dead.
He was thirty-six.
The exact cause was unclear. But both of us, physicians seasoned enough to know how these stories often end, understood alcohol was likely somewhere in the room, if not at the front of it.
We sat in silence on the phone for a few moments. No gallows humor. No clever line. No diagnostic formulation worth offering. Just two doctors, older now, holding the same invisible weight from opposite ends of the line. A painful reminder that experience does not protect you from grief.
We shared an invisible but distinct pain: the knowledge that only the two of us fully understood who Frank had been in all his improbable dimensions. Not just a death notice. Not just another chart closed, another name entered into memory and lost. We knew the strange fullness of him, the seriousness with which he delivered absurdities, the elaborate worlds he built when his mind caught fire, the charm, the stubbornness, the creativity, the cleverness, the humor he never intended to be humor, the dignity he somehow carried even when reality abandoned him.
We both knew that outside of those exam rooms, much of Frank would go unrecorded and unremembered. To most people, he would become a brief explanation, a difficult chapter, a cautionary tale, a bland line spoken at a mostly empty funeral. But to us, he remained vivid and complicated and alive in the way certain patients stay alive only inside the memory of the people who treated them, accepted them, and cared for them when much of the world no longer knew how.
None of this was said aloud. It did not need to be. We had both spent enough years in medicine to recognize the language of silence when it arrived.
All of Frank’s identities—agent, mogul, rapper, novelist—were grand titles for a man whose real battle had been much harder, much deadlier, and far less glamorous. At the end of the day, he was just a person trying to survive an illness that kills quietly and often young. Alcohol contributes to roughly 178,000 deaths annually in the United States, making it one of our most hidden and socially accepted executioners.⁴
We never save enough people from it.
But we remember them.
And sometimes, long after the chart has closed, memory is the final act of care we have left to give.
Footnotes
1. Mason BJ, Quello S, Goodell V, Shadan F, Kyle M, Begovic A. Gabapentin treatment for alcohol dependence: a randomized clinical trial. JAMA Intern Med. 2014;174(1):70–77.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: APA; 2013.
3. Hunt GE, Malhi GS, Cleary M, Lai HMX, Sitharthan T. Prevalence of comorbid bipolar and substance use disorders in clinical settings, 1990–2015: systematic review and meta-analysis. J Affect Disord. 2016;206:331–349.
4. Centers for Disease Control and Prevention (CDC). Deaths from Excessive Alcohol Use in the United States. Updated estimates report approximately 178,000 deaths annually attributable to excessive alcohol use.
5. Kyaga S, Lichtenstein P, Boman M, Hultman C, Långström N, Landén M. Creativity and mental disorder: family study of 300,000 people with severe mental disorder. Br J Psychiatry. 2011;199(5):373–379.
