Sunday, November 27, 2011

Advent - St. James Anglican Church, Vancouver

The service starts at 10:30 am.  For some reason this morning I thought it started at 11:00 am.  So I ended up at the service somewhere after 11:30.  Better late than never. It's very dog friendly and Gilbert loves his visit with all his friends too.
The Advent Candle was lit.  I was thankful to see that.  Advent is the season of the "coming".  It's uplifting and hope inspiring to prepare for the 'coming of Christ'.  IMG 0210

Dickinson Marine Mediterranean Propane Galley Range

I love Dickinson Stoves. James Giesbrecht just installed a new Dickinson Marine Mediterranean Propane Galley Range on my SV GIRI>  It's skookum.  After 25 years I couldn't get parts for my old Force 10. That's always a concern in marine world so often a reason now I stick with the mainstream on the big items.
This Dickinson just makes me want to spend the day cooking. I love all the safety features too.  Having shot a deer this fall I've already made venison stew and tonight just had venison steak.  One day soon I'll use the oven.  I can't wait till Tom, my sailing buddy, who made the best bread on our return sail from Hawaii, checks it out.  Looks great in the galley too.  Does wonders for spiffing up the old boat.
I've had Dickinson Diesel Heaters for over 25 years. James earlier this year  installed a new Newport. I'd tarnished the outside of the old one with too much neglect of salt water coming through the port windows in heavy seas and blows. It had done me for decades too. I've certainly needed the heat winter sailing on the north Pacific coast.   Rather than trying to clean up the old one, I was glad to have a new one.
I depend on my stoves and really appreciate Dickinson engineering for the efficiency and safety.  Flames and boats are worrisome so it's good there are experts.
So here  I am, warm on a winter's night, eating a hot home cooked meal and loving it.  NThank you, God!IMG 0188IMG 0187IMG 0214IMG 0218

Granville Island Broom Company

I enjoyed my walk with Gilbert around Granville Island.  When I lived on my boat in False Creek I so enjoyed dinghy shopping at the market. I've always told visitors to Vancouver that Granville Island is the definite must see.  The restaurants are the finest and range from great breakfasts, lunches and fine dinner dining. Especially good seafood.
Today I was Christmas shopping and walking Gilbert.   Lots of new shops.  Some favourite old ones gone.  The market and the little mall aren't dog friendly so I didn't get to go in there. There's quite an expansion of the shops further along filling in the expanse around Emily Carr.
That's where I found the Granville Island Broom Company. Since hearing Westjet and Air Canada aren't allowing pets at Christmas, so Gilbert won't be able to visit Dad, perhaps I was looking for an alternative solution.
The traditional brooms here are magnificent. You could definitely see them being used for flight.
I had a more prosaic use for the broom, however.  Sweeping up after Gilbert, the dog ,and Angel, the cat..
I was pleased that while they had more expensive state of the art creations they had perfect little $25 hand made brooms that would serve us just fine. I do think mine was the simplest., given the variety of intricate and expensive carved wood handles they had on some of the others. IMG 0216One of the owners was busy making brooms but took time out to ring my purchase up.  She didn't look at all witchy in the old fashioned sense.  No hooked nose.  More like the pretty "Bewitched" witch if anything.
I just figured though with Christmas coming and stables needing cleaning this was certainly a fine place for gift shopping, especially for the homes that have everything.  If I got some of my friends or family one of these creations, they'd put it up on the wall and think it 'art'.  That's where mine is now.  Adding to the decor.  I just hope it inspires me to clean up after the two animals I work for.IMG 0211

Thursday, November 24, 2011

Marijuana and Mental Health Controversy

The controversy surrounding marijuana as medicine has changed dramatically in the last 20 years.  20 years ago it was clearly 'illegal' and as such using it was evidence of 'addiction' as the risk/benefit ratio was so negatively weighted with potential incarceration and long  term negative consequences of criminal record.
These days the 'value' of marijauana continues to be supported especially with newer pharmaceutical cannabinoids seeking approval every month.  Further the federal Canadian political legislation has essentially 'decriminalized' marijuana by making it a 'medicine'.  Even in California someone wanting to smoke marijuana just needs to create a disease category, present with symptons and go to the drive through marijuana clinics making millions with the new laxity of the laws there.
There is still no support for 'smoke' of any kind.
But there's really good evidence for it's benefit in spasms and chronic pain especially 'neuropathic' pain (nerve pain) and also with nausea.  The benefits of the pharmaceutical components of standard marijuana are clearly outweighed by 'smoking', marijauna's dangers being essentially the same as tobacco smokers with chronic respiratory disease, cancer, asthma and heart disease associated with smoking. Smoking isn't good for you.
So marijuana cookies and tea are probably okay especially for Multiple Sclerosis and Nerve root pain in Diabetics. It was once the drug of choice for nausea in cancer treatment but better drugs have been developed.  The trouble is marijuana 'users' want to 'smoke' it suggesting that the majority of such are using it not for intrinsic slow release 'medical value' but it's ability to cause a 'high'.  Smoked marijuana is decidedly the route of choice for addicts.
Cesamet, Nabilone and Sativex are pharmaceutical cannabinoids.  Cesamet is on the provincial formulary for chronic pain.
The difficulty though is that 'smoking' is an 'addictive' 'process'.  This was seen with people given nicotine patches who smoked on top of that.  It's the 'ritual'.  Heroin addicts will 'shoot up' rather than 'smoke' heroin once they become addicted to the paraphernalia. There is a link between addiction and rapid access to brain of the compound.
But here's the controversy in mental health.  The Diagnostic and Statistical Manual of the American Psychiatric Association describe clearly Cannibis (Marijuana) Induced Anxiety Disorder and Cannibis (Marijuana) Induced Psychosis.  Bipolar II , the bipolar disorder associated with angry mood swings as opposed to Bipolar I where the mood swings are euphoria and depression, is the most common mood disorder in combination with addiction, clinically.  It's no stretch to say that Cannibis Induced Mood Disorder is readily apparent too.
So how do you decided if the Anxiety Disorder is a product of marijuana use or helped by marijuana use. The subjective experience of alcoholics is that alcohol makes them calmer and less violent yet the overwhelming community experience and 'objective' experience is that this is simply not the case. There is indeed a benefit from one drink and even an alcoholic will be calmed initially by one drink as a marijuana smoker will describe a joint benefiting their anxiety for a half an hour. The anxiety that follows is worse though and with addiction there is increasing need for more substance with decreasing benefit.
Initially a marijuana joint might cause hours of 'calm' but in the addict a half hour is a good success.  The alcoholic will get maybe 10 minutes of benefit from a shot when they're in withdrawal. Indeed the 'anxiety' and 'irritability 'seen in addiction is 'withdrawal.'
If you are using a substance that has caused the addiction to treat the anxiey which is the way the 'withdrawal' is experienced, then it's like pour gasoline on a fire.  There's that briefest moment when the fire is 'doused' but after that the fire is clearly a whole lot worse.
As early as the 30's alcohol withdrawal was called 'restless, irritable, and discontent", "the RID's".  Marijuana has been called 'marijuana maintenance' for those who mixed alcohol and marijuana or switched from alcohol to marijuana. Regardless the marijuana 'withdrawal' is experienced as the 'RID's" as well and lasts weeks if not months.
Drug seeking addicts will always tell me that they felt anxious off marijuana, alcohol or heroin in fact.  The truth is that those who develop addiction had an underlying 'anxiety disorder' and were 'self medicating'.  Normal people don't 'self medicate' and control the use of substances reasonably because they don't have the same underlying anxiety disorder.
Once an addiction is established it takes at least a year, some say 5 years, to be over the addiction. Seasons, 4 of them, seem to be associated with differing 'trigger's' for relapse.  So 'recovery' is not considered to be 'weeks' or 'months' but rather 'years'.
So what to do when a marijuana smoker is 'bullying' and even 'threatening' you and definitely angry if their agenda is thwarted in any way, when they see the doctor and ask for his support in getting them the 'license' to smoke marijuana.  It's said on the 'street' that 'good' doctors 'sign' and 'bad' doctors don't.
The government and it's regulatory bodies are all giving mixed messages but mostly their song is 'opinion poll' and 'cover your ass'.  As usual, clinicians, like soldiers are on their own, damned if they do and damned if they don't but certain to be judged by "monday morning' quarter backs with sometimes years to mull over a decision the clinician must make in the 'real world 'of 'here and now."
I'm in the middle. I've definitely supported 'medical marijuana' for some patients and am wholly behind 'decriminalization' of drugs, drug court and yet I draw the line at full 'legalization' because it will increase the risk to those who are vulnerable and society at large will definitely have more traffic accidents and work accidents and psychiatric problems.
I'd like to be 'black or white' in this grey area.  It's the same with benzodiazepine (valium type drug) prescriptions where patients who are addicted to marijauna, or alcohol or heroin say that the 'benzos' take the edge off.
My oath is 'do no harm' .  In the short run there are 'benefits but in the long run I'm probably at risk of compounding the patients problems.
Each case I think is unique but the politics treat the world as a mass and certainly the marijuana promoters are 'recruiter's and have a 'conflict of interest'. I've none but it's a challenge and I thought it worth mentioning.

Wednesday, November 23, 2011

Vancouver Homeless

It's difficult to hear about Vancouver 'homeless' problem without thinking that it really is 'Canada's Homeless" problem. I work in Vancouver Downtown Eastside and it's obvious that so many of the homeless have come from eastern Canada.  There's a season factor and a 'drift' factor.  You can't live on the streets in Winnipeg.  So people without a place and no opportunity out east move west.
Amsterdam just denied outsiders access to marijuana because they'd become Europe's drug addicted capital.  Vancouver is Canada's and the homeless problem has a lot to do with drug addicts from the east seeking the better climate that is so attractive in Vancouver. It rarely snows in Vancouver. I ride my motorcycle year round. I certainly couldn't do that in Winnipeg or Ottawa.
Further, there is a 'homeless' problem in Vancouver because Vancouver is the most attractive city in Canada with the highest priced downtown real estate. Further there are tremendous services for people in Vancouver and tremendous entertainment opportunities, not the least of which is Stanley Park and Granville Island.  It's a beautiful city.
There is no 'homeless' problem per se in Kelowna or even Prince George.  Not surprisingly the cost of land per square foot is a tenth of what it is in downtown Vancouver.
I think often talking about the "homeless' problem in Vancouver is kind of like talking about the 'homeless' problem in 'Rodeo Drive' Los Angeles.
Some of the 'homeless' problem is down right 'entitlement' with people naturally demanding to live in the centre of the most beautiful city with the most temperate climate in all of Canada.  Some of it is Canada's problem transferred to Vancouver.
The sad part is the much of it is the seriously mentally ill. The stigma of mental illness and addiction makes these people 'homeless' simply becuase they're not 'cuddly' like spotted owls or 'pretty forests'.  No one cares for their fellow man when they smell, are angry and afraid and often are cognitively impaired.  This is not new. That part of the 'homeless' problem is just a continuation of the old story which is 'it's okay to abuse the mentally ill and those suffering the disease of addiction."

"Girlcott" Ashworth's Fat Women Lingerie Store for Male Bashing!!
I was irked to hear on CBC "This is That" that Ashworth Department Store Winnipeg had banned men from the Lingerie Department. I've been buying lingerie for wives and girlfriends, among others, for a quarter century or more.  In fact as I've become older and my partners too the old standbys of jewelry, lingerie, flowers, perfumes and chocolates have tended more towards jewelry, lingerie, perfume and flowers.
When I lived in Winnipeg, I can honestly say I never bought lingerie at Ashworth's because it was specialized in 'fat old lady' lingerie.  Everyone in Winnipeg knew the best place for lingerie was St. Boniface. Who but the French know anything about women's sexy things.
Today I work with Transexuals and am thankful that the lingerie departments in Vancouver, especially Sears and Hudson Bay,  as well as all the top lingerie stores are notoriously 21st century in their approach to Victorian underpinnings.  My patients often men in the process of undergoing sex changes don't need the kind of sexist attitudes of gender bigots of Ashworth's.  None of my female patients who are in the process of becoming men have ever had to deal with the likes of Ashworth's Helen Cole-Adams when they buy Stanfields for themselves or get those James Bond pjs for their romantic encounters.
Naturally I don't think 'teen age girls" have any place in men's underwear departments either. So I didn't like hearing men and 'teen age boys' lumped together in an obvious 'marketting' strategy.  What real adults don't think twice about 'sex' at all, confronted with any teen agers in their midst?
In fact I was rather delighted to buy an item this summer for my girlfriend at  La Vie En Rose on south Granville Street here in Vancouver.  She was so pleased she said, "because 'that's where Goldie Hawn shops".  Now Goldie Hawn took 'sexy' and "romantic'  to a whole new level.  I don't think she ever objected to men being around her. If anything she still has to beat them off.  So Ainsworth could well learn something from La Vie En Rose!
Is  Ainsworth  really Winnipeg?  When I lived there Winnipeg was  a Canadian 'fashion capital'.  Admittedly Montreal, Toronto, Vancouver and Calgary have all long surpassed it as such. But is it really becoming a place where lingerie is so bad it has to be cloistered and sold only to nuns who faint at the sight of man, especially a man who might well be buying lingerie for himself or herself.
I plan right now to throw a temper tantrum the next time I see a girl reaching for my Stanfields.  I can't concentrate when women are around me buying those 'boy boxers' the young girls love to 'pilfer' from the men's underwear store.
Ashworth's is pathetic.  I hope their fat woman lingerine store gets 'girlcotted'.  It's likely that  on line Victoria Secret will benefit from the likes of Ashworth.
I expect with that attitude in Winnipeg now, all the sexiest and finest women will have to wait till their next trip to Vancouver where they can shop at La Vie En Rose or  Dianne's on South Granville.

Tuesday, November 22, 2011

Mayor Gregor Robertson, Congratulations!

Gregor Robertson won the Vancouver mayoral election beating Susan Anton.  Susan Anton gained significant popularity offering to reduce bicycle lanes disrupting the centre of the city and getting tough with the squatters of the protest movement, Occupy Vancouver.  Mayor Gregor Robertson won with cool head and soft spoken assurance that with patience not only would Occupy Vancouver be moved to accommodate the City Christmas festivities but also that it was no fault of his own that the rioters following the Canucks games had not yet been brought to justice.  Steady and determined Mayor Gregor Robertson, with even more experience, enters another term.  The near success of Susan Anton's campaign will no doubt influence Gregor Robertson's Vision. 

Thanks to the Mayor and City Vancouver remains one of the most envied, admired and popular cities in the world.  Despite exorbitant housing prices which speak to it's popularity it continues to grow with ever improved transportation.  

Sunday, November 20, 2011

Canada's War in Afghanistan

The Canadian troops are home. The heros are buried. The wartime marketeers are pleased with themselves. The media are jackals. The armchair philosophers grow fat.
I am thankful for the service that the Canadian Military performed. I was so embarrassed by the nit picking opposition while Canadians died in horrible conditions far far from home.  I have no memories of the soldier who died saving his platoon. I have no recollections of the men and women who fell in combat. Thanks to CBC and the opposition I'm left thinking there was something wrong with Canadians giving prisoners of war to their Afghanistan compatriots.  The Canadians were gentlemen and ladies compared to the terrorists who willy nilly captured westerners, tortured and killed them.  But all I recall are dead Canadian soldiers and the criticism they received for doing their duty.  I would have liked to have known the acts of heroism more.  I would have liked to have had coverage of the war such that today I could say what the campaigns were and where outside of Kundahar the Canadians served.
Now the jackals say the dead are wasted and the soldiers were fools as if this was Vietnam and they don't realize the world has changed.  Give a boy a hammer and everything is a nail.  I do believe the Canadians did wonders. I believe they showed Afghanistan what was outside of their primitive war torn tribalistic gangster world. I believe they showed them that women could be equals. I believe Canadians showed the world that we can fight as well and fair as anyone and we don't have believe in gangsterism and bullying and brutality.  I believe that NATO showed the people of Afghanistan that nations could cooperate where so often they are still fighting village against village. We showed that Canadians can fight too with less resources and less equipment and less support than so many others received.
The question is what would have occurred if we had not served NATO.  The critics would say it's okay to renege on our committments and mutual defense aggreements.  They'd gladly have England and France and Germany and the United States protect little Canada from the big bad bullies.  But other Canadians, like Prime Minister Harper, know the importance of participating in a global community and accepting that someone has to step in and show the bullies that there is a cost to terrorism.  Canadian troops stemmed the tide.
Were it not for the Canadians in Afghanistan I believe that the democracy demonstrations that occurred all across the east this summer would not have occurred. I believe that Ghaddafi would still be in charge in Libya and training terrorists to attack Israel, United States and yes, Canada.  I believe that were it not for Canadians fighing in Afghanistan China might well have invaded India again.
Without Canadians in Afghanistan, Afghanistan would now be joined with Iran and the worse faction of Iranian politics would be supported by the Taliban. Without Canadians in Afghanistan more women and children would have been sold as slaves and killed.
The Jihad would be further ahead and more arms would be sent to northern Sudan so that those Sudanese could kill the Sudanese Christians in the south.
Were it not for Candians in Afghanistan, Bin Laden would still be in charge of the Akaida and more pirates would roam the seas off the Phillipines.
Let's get real, Canadian soldiers in Afghanistan gave us all more time to deal with the increasing problem of terrorism and fundamentalism.  Canadians died and thanks to their deaths this country has had  freedom and peace.
Without Canadian soldiers in Afghanistan, Israel would have been wiped off the face of the earth taking countless Palestinians with them as 'collateral damage'.  Nuclear bombs would have gone off , for sure.
If Canadian soldiers had fought in Austria before WWII, Hitler would not have had the "peace' to build his armies that turned the globe into a war zone.  Canadians in Afghanistan served with dignity.  They saved the day.  The did their bit. Their contribution should not go unnoticed.  As a country we should be immensely thankful for their contribution to world security.
Alternatively we could disarm unilaterally.  We could dismantle the army and collectively become vegan and offer blossoms and scents to calm the barbarians that would come across our borders and sell the women and children into slavery.  We could offer  the next cannibal we meet with a fruit bar while we are at it. Otherwise we should view the world as it is and stay 'real' while admitting yes we should all get a long and sing 'kum ba yah' but some of us aren't quite there yet.   I am thankful that the Canadian military surely knows "kum ba ya' whereas our enemies don't. But I'm even more thankful that the Canadian miltary was able to go to war and hold it's own admirably.  The Canadian military deserve our respect and praise.

St Andrew's Ball, Vancouver, BC 2011

The St. Andrew's Ball hosted by the St Andrew and Caledonian Society celebrated it's 125th year being the oldest Scottish society in existence in Vancouver.  It is the premier social event for the Scottish community though Robbie Burns Dinner and Highland Games in Port Coquitlam in July attract more, for sure. We learned from the delightful Kayla that the proceeds were part of the fund raising for the Scottish Studies and Piper Band at Simon Fraser University. Heather, a beautiful lady,  one of the program organizers came around and personally welcomed us.
The St. Andrew's Ball though had David Lundy as Master of Ceremonies doing a masterful job, piper Kim Reid, soloist Wilma Paton, the Royal Scottish Country Highland Dance Society, the Vancouver Fiddle Orchestra, Grace by Maureen Baird, Donald Paton addressing the Haggis, Honorable Chief Justice, Lance Finch, toasting the Queen, and Cilla Bachop toasting the Twa Lands.  The men were mostly dressed in suits but those highland kilts  cut a fine form on the dance floor while the ladies gowns and scarves were truly magnificent.  The Vancouver Marriott Pinacle Hotel did a fine job of rising to the occasion serving a delicious meal.
It was an event where Scots drank Scotch and we were informed that on average a Scot travelled some 900 hundreds miles a year on foot and drank some 20 gallons of liquor, so that it could be deduced that an Average Scot got over 41 miles to the gallon.  The dancing was splendid. There was a Grand March and then we formed 4 and 3 couple groups  to be lead through ancient parlour dances with much confusion and increasing fun as the night moved along.
I loved the piping of Kim Reid that filled the foyer of the Marriott and assured us we'd arrived at the just the right place.  The beautiful Wilma Paton's solo, Caledonia brought tears to my eyes and I so enjoyed the Toast to the Twa Lands, Scots celebrating their homeland of Canada.  What a grand occasion!
Our accountant friend, Lorne Kay, drove in from Chilliwack so we could continue our long standing banter about whether the Kay's or the Hay's contributed more to the River Tay.  Laura, a Murray and a Dunn, simply loved the elegance of the evening though she discretely passed her portion of haggis to me durIMG 0164ing the dinner. DSCN9787DSCN9784IMG 0151IMG 0155IMG 0159IMG 0163IMG 0154IMG 0169DSCN9799IMG 0170IMG 0171

Saturday, November 19, 2011

Psychosomatic Medicine

Pscyhosomatic medicine doesn't mean "it's all in my head".  It means rather that the 'head bone is connected to the toe bone'.  Without your head you'd not experience any medical condition. The fact is that all medicine and surgery is 'psychosomatic'.  By convention and the dualism of Greek philosophy and later Descartes people began to think of their 'body' as somehow disconnected from their mind.  Modern "mind-body" medicine tries to overcome this limitation. My hand is truly separate and different from my arm but they share a common nervous system, circulation and lymphatic system. Indeed the more advanced the medicine the more recognition of the interconnectedness of the parts.
I started my career with a surgical internship. I wanted to be an orthopod, to tell the truth.  I got waylaid by family practice in the country and northern medicine. It was in the thick of clinical work I saw the importance of depression, psychosis, drugs and alcohol, attitudes and beliefs to health.  I decided to study psychiatry with the purpose of advancing my understanding of bodily illness in many ways.  I learned a tremendous amount in psychiatry about disease in general and mental health in particular.  At times though the psychiatrists themselves were all too much in their heads.  Just as family practice was revolutionalizing to a greater awareness and understanding of community, family and the individual as those contriubted to physical health psychiatry was fleeing from embracing the whole realm of psychosomatic illness and instaed focusing on 'brain disease as if the brain was somehow floating disconnected from the body.
The Ericksonian Foundation based on the pioneer work of American psychiatrist , Dr. MIlton Erickson along with the Palo Alto School and other key centres of research was a place where I found a home a way from home. At the huge medical and psychological conferences of the Ericksonian Foundation in Phoenix I met others interested in the efrects of faith on healing, how exercise promoted health, nutrition and it's influence on mental health, and all manner of psychosomatic ideas far too advanced to be embraced by the increasingly rigid orthodoxy of psychiatry. I followed cardiologist  Herbert Benson, and Internist Bernie Segal's work with rapt attention. Later I'd love the medical magazine, Psychosomatic Medicine.
I would too often attend a psychiatric confrence and hear more about treating the 'brain disease' without consideration of the human holding the brain and how their mind was altered by disease, their relationships and their community.  Always I thought in 'systems' and interactions but I'd be frustrated by those around me who seemed to think that equations could only flow in one direction as if they had not studied biochemistry as I had.  I found the ecologists and community medicine doctors and more and the addiction medicine docotors were thinking in the broadests sense while not missing the details.
It's not surprising that I've ended up in addiction and trauma psychiatry with an interest in consultation liason neuropsychiatry.  Every organ in the body is affected by alcohol and drug abuse.  Alcohol increases throat and bladder cancer, diabetes, heart disease, depression and community violence as well as poverty.  Drug abuse such as crack causes micro infarcts, causes MRI changes in the frontal lobes, afffects immune systems, marijuania causes early psychosis which can persist as lifelong schizophrenia, as well as causing lung disease and asthma from the smoke inhallation. Heroin is as much a community problem as an individual problem. The opening of a methadone clinic in a community can reduce theft there by 25% or more saving the inhabitants of the community millions of dollars a year.  Yet addiction is a mental illness as well as a physical illness and a matter of public and community health.  I'm delighted to be among colleagues who while working for a 'brain' disease 'cure' don't seem to think in rigid isolation but rather see the issues in the microcosm and the macrocosm.
In consulataion liason and neuropsychiatry the wide ranging effects of head injury or crohn's disease, diabetes, cancer, or multiple sclerosis are not limited to the cellular damage or the initial injury. A head injury commonly becomes a life long disability no different than loss of a finger or limb while often concurrent mental illness affects how a person will recover from surgery.
Psychosomatics is medicine and it's surgery.  The idea that the body exists in isolation is long gone.  People with depression develop physical illness more readily just as the Rahe Holmes studies showed the significance of stress on body illness. Similarly people with bodily illness are more prone to develop mental illness. Patients with chronic pain from arthritis commonly develop depression.  The use of prednisone, a life saving medication, is commonly associated with psychosis and mood disorder.  People with infections commonly develop panic and anxiety.
All teaching hospitals have a consulting psychiatrist as part of the team of physical doctors who work in hospitals, medical and surgical, wards, because psychiatric issues arise so commonly among patients with physical illness. I was the consulting psychiatrist to a hospital and commonly called out every night on call to deal with delirium, dementia, grief and violence.  I enjoyed one old codger who was going into DT's the night before his surgery and my psychiatric intervention was to make sure he had enough alcohol through the night to stop him from seizuring.  The surgeon and anesthetist were very thankful to have a psychiatrist on board.
I'm a medical doctor first, psychiatrist second.  I also had two years of residency in community medicine and public health so I not only see my patient's brain connected to his body but I also see my patient connected to his family and community. Increasingly in my work with addiction and with patients who have been in and out of jail I see that the 'system' is the old fashioned jailhouse punishment mentality that exists outside the shining light of the 'drug court'.  Yet few of my patients are fortunate enough and rarely early enough to take advantage of that breakthrough in the all too often dinosaur thinking of the criminal system.
Just last week I met with a group from the courts who were shining lights but I could see that they had had years of the frustration I'd had working with the entrenched stupidity of people trying to fight today's wars with yesterday's ideas.
I was delighted to work with a judge in Saipan who saw so clearly the need for the New York solution for chronically violent mentally ill to be discharged to the community only on condition of being on long term injectable antipsychotics. Like the drug court which uses urine testing for drugs as a conditon of freedom these 'systems' are working now with psychiatrists who are trained as much in psychosomatics as community to achieve what is best for the patients and society. Often an ethicist and leaders of the patients failth community are brought together to ensure that an individual decision doesn't lead to an abuse of human rights in general.
At times I miss the idea that "Mr. Jones is the 'kidney' in hospital bed 3" or Mrs. Smith is the 'mental case' in hospital bed #4.:  It's always easier to think like administrators and reduce people to nazi numbers but the fact is I like people as people with all their diemensions. Increasingly too it's the spiritual dimension that moves me. That said I'm thankful for enlightened administrators who with great humanity can actually move the ship of state away from the rocks in a storm.
People are not only connected to community but it's been said 'anxiety is a measure of your distance from God".  I don't think of God as the Santa Clause tyrant on the cloud. I rather like Bishop Spong's debunking of the Christian God and the Jesus Convention work on the History of the Bible.  God in a 'spiritual' sense is about all those imponderables.  What do I believe is my 'purpose'. What are my thoughts about the meaning of life. It's not that there's an answer to these questions in general but how I answer them specifically is critical.
Just last week I met a depressed woman who said she thought the world was going to end so there was no reason for her to even think of marriage and children. Yet that's what she had wanted till she'd embraced that pseudoscience of nihilism.  Her noncompliance with medical regimen, refusal to care for herself and refusal to take medications for her illness was tied to the central questions of her life.  I think that's where the 'spiritual' lies.  It's all those questions and sometimes arbitrary working answers that get us through the night. It's not that 'prayer' is right or wrong but it can work quite amazingly. just as confession, asking for help, meditating, doing yoga, chanting, singing hymns, going to a concert, dancing can all contribute to health. It's the wholistic that's God or the Good in life.
I once wrote I didn't want someone to give me a bag of whole grain riice when I needed admission to an intensive care unit but I knew then that eating whole grain rice, as just one example, could help me avoid admission to an ICU. The more we learn about chronic illness the more we learn that they are psychosomatic illness of lifestyle. It's time to embrace the idea that the head bone is connected to the toe bone just as the toe bone is connected to the headbone as we live in relationship with all around us.

Friday, November 18, 2011

Ballet BC - Three Fold

Another sensational night at the ballet.  Diversion by Robert Glumbeck was original and intriguing with extraordinary modern dance.  Walter Matteini's Parole Sospese was downright weird in the best of way. Right out there.  Existential wonderland.  Simone Orlando's Doppeling was retro at it's finest.  Normally I'm simply enthralled by Maikalla Wallace, Alexis Fletcher, Dario Dinuzzi,  and Gilbert Small.  I love the wisdom of their experienced dance interpretation. Yet tonight all the members of the company stood out.  Rachel Meyer was so fresh, Andrea Pena passionate and Alyson Fretz sophisticated in a particularly European way.  Connor Gnam and Alexander Burton were particularly outstanding.  Rachel Prince, Peter Smida, Maggie Fogeron, Livona Ellis, Jed Duifhuis, Chisto Ide, Daniel Marshalsay, and Darren Devaney all were a delight. I'm sorry I can't put faces to names with some of the older and some of newer members because all their pas de deux, leaps and lifts deserved individual mention after tonights superb dance performance.  I truly think that Bach would love what Simone Orlando did for his timeless music. Kate Burrows, Linda Chow and Ina Broeckx's costume designs were genius. Artistic Director Emily Molnar continues to inspire. We are truly blessed by her and Executive Director, Jay Rankin's vision.  Tonight Fasken Martineau was celebrated as Season Sponsor.IMG 0136 IMG 0138IMG 0141IMG 0139IMG 0137IMG 0143IMG 0135

Thursday, November 17, 2011

Opioids for Chronic Pain - CSAM Position Paper 2011

On Nov. 5, 2011, at the Canadian Society of Addiction Medicine annual scientific meeting, Dr. Ronald Lim and Dr. Nady el Guebaly presented on CSAM's new position for use of opioids in chronic pain.  I took some notes and compikled this blog based on those simply to share the highlights of the discussion. This is a very hot and controversial topic that affects the majority of physicians in clinical practice.  I was very thankful to see that concerns of patients and clinicians were so well addressed in this complex field.

This position paper was developed in response to
  1. concerns regarding patient and public safety risk from opioids
  2. Rising rate of rx opioid abuse
  3. Rising rates of illict use of rx opioids

NOUGG - National Opiate Use Guideline Group was the research team  set up with physician/epidemiologist, four physician researches, and research librarian to study research to date and bring findings to the National Advisory Comittee
6,580 studies identifed
184 met inclusion criteria
Concerns regarding patients and public safety were raised.
Canada recorded rx opioid consusmption increased by 50%
Canada is current the third largest opioid analgesic consumer per capita
Dhalla 2009 showed that 1095 overdose death in Ontario, 56% had been given opiod prescription within 4 weeks before death
Study of oipiod depent patients, 37% receieved their oidiod from physican prescriptions
Kuehn 2009  noted increase in rx and increase abuse, serious injuries and overdose death
In patients with history of substance abuse
prevalence of aberrant drug related behaviour 11.5%
urine drug screens with illicit drugs 14.5%

Investigation of the evidence of opiod efficacy was best for the following:

diabetic neuropathy
peripheral neuroptahy
postherpetic neuralgia
phantom limb
spinal chord

In other conditions the evidence was mixed or absent:
Fibromyalgia - no randomized trials of strong opiods
of the trials, tramadol, shown best.
small benefits outweighed by increasde adverse affect
neuropathic pain - subjective improvement was noted but not not that significant when compared with  functional status. Patients felt better but didn't appear to 'do' better with the subjective benefit.
Migraine, tension headaches
opioids not indicated

A major recommendations was associated with discontinuing opioids:
-opioids should be tapered and discontinued if patient’s pain remains unresponsive after trial of several differnet opioids.
This was a critical piece of information given the clinical tendency to start opioids and believe they are beneficial when they haven't shown benefit and then leave them in place for fear of addressing the issues of discontinuance.
Further recommendations included the following:
definition of addiction in context of pain treatment should be clarified and concerns should clearly be raised if the following are noted:
1)Continued opioid use despite adverse consequences
2)Loss of control
3)preoccupatins with obtaining opioids despite adequate analgesia
4) denial of a problem
There were very important recommendations regarding physician training in this regard, consensus being that physicians needed specific training and that specific training would go a very long way to reducing concerns re safety and abuse.
Physican prescribing should be appropriately trained  and physicians should ,perform documentend compreshensive training

Further, "medical legal consequences should be muted". If physicians were supposed to prescribe opiates for severe and chronic pain in appropriate situations they should not face overwhelming negative consequences for doing what was best for the patients or else physicians would have no choice, really but to feel that they were getting a mixed message in which 'ommission' would be rewarded but where 'commission' would be punished.

Opioid prescribing for chronic non-cancer pain

M.Kahan, R. Lim, N. el Guebaly Sept 2011

1.Careful patient selection
2.First line opioids - WHO pain ladder
3.Dose titration - should improve function, reduce pain by at least 30% (10 pt), mostly well below the 200 mg morphine oral range
4.Overdose prevention
5.Screen for addiction risk
6.Opioid tapering - lack of response to high dose
  1. Management of high risk addiction
  2. Management of suspected addiction
  3. Treatment options - structure opiodi therapy, opioid agonsits
This will be published in the Can. Journal of Addiction Medicine

The discussion continued with recommendations for Public Health, defunding the 80 mg Oxycontin, and de linking Buprenorphine prescribing from Methadone, being addressed.  The discussion, in fact , was rather exciting suggesting participants not only appreciated the presentation but working themselves in this difficult area had many questions and ideas to share.  It was clinically very elucidating.

I have survived waking up another day

I have survived waking up another day,
The old car with a hard start on a cold winter morning,
The ache and pain of lost youth,
The coughing sputter of engine refusing to turn over,
Choking, gasping, sucking air
Praying, begging, rolling over,
Fighting through the worrying dog and cat,
One wanting food, the other needing to pee,
Toilet pit stop bringing certain relief,
Dressing a chore, especially the shoes,
The overcoat barely breaks the chill wind,
But the dog's ecstacy uplifts.
And walking,
The old car gathers steam,
Takes the corner like a pro,
Follows the lead dog,
Leaning into the wind,
Making the coming home turn,
The dog having done his business discreetly,
Saving me the effort of bending and picking up,
My engine veritably roars in the home stretch,
Imagining the smell the brewing coffee.
After a shower, dressed in work clothes
I'll look like something new and fresh,
No one would believe I barely survived this morning.
How easy it would have been to roll over and gone back to sleep
Hiding in that other world, uninterrupted
Except for the occasional nightmare, these days.
The cat now eats her breakfast
And the dog is looking relieved.

Tuesday, November 15, 2011

Bushnell -Fusion 1600 ARC Laser Rangefinder Binoculars

Bushnell - Fusion ™ 1600 ARC 10 x42 mm [201042] > I bow hunt and rifle hunt and I'm a blue water sailor.  All my scopes are Bushnell. I've been really quite satisfied with Bushnell binoculars especially considering the price. When the Bushnell - Fusion Arc became available  I bought them. I'd read about them for a month or so before I saw them in 100 Mile House hunting outfitter store.  They lived around my neck the duration of this season and will accompany on my sailboat as well.  I'm delighted with the clarity and magnification of the binoculars. They're as good as any I've had for hunting letting me see well at dusk and dawn. What's fascinating is the range finder. There's enough features for a cyborg but what I simply like is pointing at something estimating the distance and then finding out the exact amount. I've routinely off 10 yards either side of an object. The first time I estimated an object was 100 yards it turned out 85 yards. Now I'm training my vision. It's a lot different being in the woods and on trails than at the range. I actually set my targets up more correctly. I expect these binoculars could even improve my golf game.  So I just wanted to share that as far as 'boy bling' goes, these have really done it for me this year. DSCN9773

Monday, November 14, 2011

Attack on Leningrad - Movie

In spite of myself I watched a disturbing human drama of historical significance. I picked up the DVD kind of thinking I'd enjoy watching some fast action plane fights done up Russian style. Instead I weeped at the terribly touching story of two women, others, and the children.  There were planes and tanks and bodies lying dead to be eatten in the seige of Leningrad.  But there was also this moving moment when a father tells his departing daughter, "Don't give up."  Action packed, for sure. but spilling over with humanity as well.  Not at all comic book or cut out people. Acting so real by Mira Sorvino, Garbiel Byrne and Armin Mueller--Stahl and Olga Sutlova.  In the Nazi seige a British Journalist Kate Davis is presumed dead only to be rescued by Nina a member of the Soviet militia.  With papers lost and declared dead Kate stays starving and surviving with Nina's family.  Alexander Buravsky is the director.  The movie was so much more than I imagined.
In the end I felt like I'd just watched Dr. Zhivago expecting an episode of House MD.

Merrit B.C. Hunting with Luke and Gilbert

I began Veterans Day by phoning my father to thank him for the peace and liberty I'd experienced in my life thanks to his service in the Royal Canadian Air Force.  At 92 he'd slept in and thanked me saying, "I'd better get up and see what's going on today."  I headed out then with Gilbert to pick up Luke for the last weekend of moose hunting in area 3, Thompson. Merrit BC was our destination.  Luke had his gear ready at his home in Kitsilano so that was the briefest of stops be fore we headed over to North Vancouver to pick up my gear.  Then it was a road trip.  Gilbert loves the fast food meals stops on road trips, always getting his single fried meat paddy as part of the hunting crew.
In Merrit we made our basecamp at the pet friendly Ramada Inn.  We were out in the darkness and on site hunting before dawn. We were back at the hotel after dark.  We did everything by the book and had the drill down to a t. The only trouble was the moose didn't show. We did see a 2 point buck which would have been easy pickings except it was 4 point buck only season and Gilbert began barking shouting in dog, "Don't shoot, it's only 2 points."  Before we could understand his message he was getting shouted at. The deer departed.  We never saw a single moose. Tracks of deer and moose were everywhere.  But what we did see were wolves. Incredible animals. Up close and unpleasant.  We saw 4 altogether.  Big black ones that ran at the sight of us.  Luke saw a bobcat.  I shot a grouse.  It was ATV and Ford F350 truck heaven.  It was too cold for much sitting in ambush.  So we stalked with fresh snow covering the sound of our footsteps.  Luke rode the Polaris Sportsman 500 ATV loving it.  I had a cold so did a lot of driving around coughing and sneezing in the heated cab of my Harley Davidson edition Ford F350 diesel truck.  I'd tried sitting in the cold but began coughing so quickly retreated to the warmth of the truch hanging out scoping likely areas with Gilbert as my companion. Then Luke would rejoin us and Gilbert would be ecstatic.  At night we watched warm movies and westerns.  It was a great weekend that could only have been made better by shooting a moose.DSCN9752DSCN9751IMG 0096DSCN9754DSCN9770DSCN9757DSCN9778IMG 0103DSCN9756IMG 0115IMG 0092IMG 0094DSCN9776DSCN9768DSCN9778DSCN9779DSCN9765DSCN9780DSCN9761DSCN9764IMG 0097

Wednesday, November 9, 2011

Coroner's Report -Canadian Society of Addiction Medicine 2011

Dr. Karla Pederson of the BC Coroner's Office presented their findings on the mortality associated with drug abuse.  Dr. Karla Pederson was quick to say that the Coroner's Office was there for 'fact finding" not "fault finding".  She said , "There is no good news at the Coroner's office. We see the worst of the worst".  The following are some of the notes I took but they really don't do justice to a far reaching and very compelling presentation.
Classify death
5 categories
natural, accident, suicide, homicide, undeterminied

1)RX  Opiate Death
Cases represent person overdosing on opiate medications prescribed to them
Deaths due to opiates 2005 to 2009  - consistent - 67-80 deaths each year
61% accidental
35% sucidial
4% undetermined
gender 50/50
2)Illicit Prescription death
-start as triplicate prescription
they started as legitimate prescription but went to someone else
‘street drugs’ are excluded
pharmacy robberies happen but marjority go back to a prescription pad in doctor's office
90 to 125 deaths due to diverted medication
Primarily male problem
30 -39  principal age
seen in all regions but more in metro areas and sold on the street

Illicit and Rx Opiate deaths - may be on rise
95% are accidental deaths
problem seems more criminal
3) RX Methadone Deaths
Prescription methadone
Overdose deaths where relevant drug was methadone
Methadone precribed to individual for maintenance or for pain
It's recognised that this is harm reduction model and harm reduction patient
Carries are a common theme, but no universal
Also high starting doses, too much initital dose
60% male 40% female
40 - 59
Happening in all regions
85% accidental 9% suicidal

4) Illicit Methadone deaths
Person was not on methadone
Uniformly has to be a carry diversion
40 50 yo population peak

The take home message here was 'a carry can end up anywhere".

The presentation was extremely well conceived and brought together. Dr. Pederson was a remarkable professional and handled the most difficult questions at the end with amazing dexterity. There was concern among the physicians with the direct buying of drugs from other countries and access across borders.  The contrasting message of physicians not treating pain sufficiently or clients complaining that doctors don't give them sufficient methadone replacement medication in a timely fashion was all brought together. Especially concerning was the prescribing of excessive benzodiazepines by physicians other than the methadone doctors and the respiratory failures being ascribed as a 'methadone death'.  Indeed the discussion was one of the best following a presentation and Dr. Pederson did a marvellous job of answering the wide range of questions.  Obviously physicians as well as the coroner's office were especially concerned about death.
"First do no harm" was a concern we all shared.

Sunday, November 6, 2011

Marijuana Debate - Canadian Society of Addiction Medicine 2011

Addiction Medicine Specialist, Dr. Paul Sobey refereed the marijuana debate between Canadian family physician and marijuana researcher Dr. Mark Ware and Prof. Jag Khalsa.from the National Institute of Drug Abuse.  Good humored laid back Indo American Prof Khalsa should have been the pro marijuana debater if steretypes were true. Dr. Mark Ware in comparison was such a clean cut and measured speaker by comparison. They were both extremely learned and the debate and discussion was one of the best I've heard.
Dr. Sobey did a masterful job of asking questions comparing efficacy of prescription pharmaceutical cannabinoid products, such as cesamet and nabilone,  with smoked marijuana products. Specifically Dr. Ware's research showed that smoked marijuana to date was superior in treatment of neuropathic pain associated with HIV.  Clearly there was benefit from cannabinoids for treatment of spasticity, nausea associated with chemotherapy, neuropathic pain and improving appetite in HIV patient. Other than rare examples the benefit of marijuana or cannabiniods over alternatives was negligible but physicians were generally glad to have as many alternatives as possible in their tool boxes.  . To date there had been no abuse of pharmaceutical cannabinoids noted by Dr. Ware's recent research or Dr. Khalsa's investigation.  There was a lot of 'off label' use of cannabiniods in areas where research had already excluded the benefit.  Such an example was migraines whereas there was need for more research in it's use in multiple sclerosis.
There was clear evidence agreed on by both that 'smoked marijuana' was associated with Chronic Lung Disease. Further there was overwhelming evidence that it caused psychosis and had profoundly negative mental health consequences for many.  The cost/benefit was significantly altered when the drug was now associated with causing or contributing to the development of schizophrenia in adolescents.  Further it was clearly associated with accidents, specifically motor vehicle accidents and fatalities.
Both researchers said that marijuana should not be used by adolescents.  Brain development continues rapidly to age 25 and Dr. Ware was very specific in making clear that he wanted to see more research and perhaps more use of smoked marijuana in chronically medically ill patients of older age. He was very upset that adolescents were quoting him saying it didn't appear to be associated with causing throat cancer as a justification for their using it recreationally.
Both researchers felt there was a strong need for more study of marijuana.  Prof. Khalsa was very pointed in saying that NIDA had not been against marijuana and that there were countless studies done on cannabinoids in the US. The position of NIDA was specifically against 'smoking' as there was no evidence that smoking of any kind was anything but harmful.
Dr. Ware made the telling comment that when the government introduced so called 'medical marijuana' with some 22,000 now smoking marijuana after 5 years in Canada there was no solid research component as part of this politically powered federal legislation.  Obviously any good marijuania program especially one government funded should incorporate an ongoing research component. The University of California was doing just this in the US.
With typical good humor Prof Khalsa responded to Dr. Ware's cry for more research money for the study of smoking marijuana saying that much medical research is done by private funding. There was certainly financially invested interests in the marijuana debate who had not been willing to date to back up their claims of the benefits of marijuana with research funding.  The marijuana industry certainly was making a killing but not as open to research as Dr. Ware was proposing especially in light of increasing evidence of the long term negative consequences for some and the real dangers for children, adolescents and pregnant women.
Dr. Ware's excellent scientific knowledge and reasoned  approach were a pleasant change to the usual paranoid marijuana devotee who bludgeons the medical doctor with phrases like 'organic' and 'herbal'  insisting penicillin is dangerous and marijuana is life's cure.  I
ndeed listening to both these learned men in an excellent discussion was a breath of fresh air given how smokey the discussion has been in past years.
Despite this being Vancouver, and the discussion immensely entertaining, no one lit up a joint during or after the debate.IMG 0064IMG 0068