Tuesday, October 28, 2014

Dr. Shaohua Lu - Addiction and Consultation Liason Psychiatry

It was a rainy dark night at the end of a long day of clinic.  While the Seasons is a very fine restaurant,   on such a night I'd gladly have been home.   Dr. Shaohua Lu, however. was the night's dinner speaker. His topic was Pain and Addiction, A Psychiatric Perspective.
Dr. Lu is extremely well educated in the field but more importantly he is one of the leading clinicians in hospital based psychiatry for the addicted and medically ill.  His contribution to psychiatry at Vancouver General Hospital is immense.  Personally I've always admired his knowledge and clinical acumen in the treatment of difficult and complex cases.
I've had the pleasure of treating people in the community who were seen by him in the hospital.  There had been no platitudes or stupidities, no missed diagnosis, or whacky medication regimens.  He'd given patients the straight goods and they'd returned to the community well aware of the seriousness of their illness and exactly what they needed to do to address it.
When the College of Physicians and Surgeons employed lesser qualified physicians in the field of addictions it was always a pleasure to listen to the greater experience, training and wisdom of Dr. Lu. Never a policeman, in the field of addiction where sometimes punitive controllers loved to act out their unresolved traumas of  potty training, Dr. Lu by contrast, was always a physician first, and always a gentleman.  He based his work on the latest in research and taught the basic foundations of medicine and psychiatry.
It was a packed room he spoke to that night. Two of my most seasoned addiction medicine colleagues had been at another talk sitting next to him.  Later they'd say they'd got more clinical 'pearls' from him than from the speaker. The people in this room were impressive.  Dr. Paul Sobey, a leader in the Canadian Society of Addiction Medicine, sat near Dr. Malomed from the excellent BC College of Physicians and Surgeons Methadone Committee.  Dr. Horvath and Dr. Tsung, well weathered clinicians from the DTES Docside Clinic. Dr. Durnin. with her vast clinical experience, from her practice at Pender and also in Surrey. Dr. Klajic, humorous and wise, spoke with the very bright Dr. Cohen who sat near a couple of the top East Indian clinicians whose long names I shamefully forget.  I actually asked one fellow twice and really should have written it down. There were several others too, a great turn out.  Mostly the over 40's crowd.  There might well have been another 60 year old but I fear my beard was whitest. The experience,  knowledge and collective wisdom was palpable.  The questions asked of Dr. Lu came from that depth of experience.
Dr. Lu spoke to the overlapping areas of Pain and Psychiatry, the appropriate use of antidepressant, anti anxiety, anti inflammatory medications and finally opiates. There's been much talk of abuse of prescription opiate medication.  Dr. Lu cited the appropriate use of opiates but distinguished his work with cancer patients and palliative care versus his work with 'chronic pain'.  There's clearly a different approach to dosage when a person's life expectancy is months not years.  Further he emphasized proper medical work up for pain and the importance of recognising co morbidity with psychiatric disorder.
"No chronic pain patient is without psychological consequences."
Nadine Sparks, the Senior Sales Representative for Eli Lilly Canada Inc had organized this meeting for the benefit of pain and addiction clinicians who were commonly prescribing a variety of medications to address the patients issues with complex pain.  Cymbalta, (duloxetine) is the new antidepressant the FDA has approved for pain treatment especially fibromyalgia.  No other antidepressant medication has received such approval to date though commonly the tricyclic antidepressant, elavil (amitriptylline) has been a mainstay of pain treatment.  My patients swear by Cymbalta,this breakthrough medication.
Dr. Lu never spoke to any drug or company by name, having no conflict of interest and clearly basing his discussion of the research data to date.  He discussed buprenorphine as well in the chronic pain patient and addressed the importance of exercise in the treatment of chronic pain.
Discussing the controversial topic of 'medical marijuana' in the treatment of chronic pain he cited the research that showed that the cannabinoids that help with pain are not the same that get people high. Essentially he said, "If a person is 'feeling' high on the marijuana the dosage is too high or its not the right cannabinoid medication."
He was especially helpful in his discussion of the early onset of hyperalgesia.  Most people think of opioid induced hyperalgesia as happening at high dosage whereas Dr. Lu cited low dose induction. He maintained that it was wise clinical course to be aware of this phenomena with all opioid usage but especially when the response is not what is anticipated.
It was a truly delightful presentation and I was thankful even driving home late in the rain that I'd made it out for the evening.  Yes the Season's was a very nice restaurant.  And yes, Nadine Sparks is extremely enthusiastic and convincing.  It was great too to see fellow front line workers, the clinicians who work with the patients who suffer from these ofttimes difficult but equally challenging illness.      

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