Tuesday, October 4, 2016

Canadian Psychiatric Association - Annual Conference - Toronto - What to use when your patient is using?

This was a highlight of the conference for me. It really was a main reason for my choosing to attend.  Working in the Downtown Eastside in Vancouver I looked forward to hearing how others dealt with the most complex cases where the clinician had the least amount of control.  In a hospital it’s like working in a lab.  In the community to a large extent one has some reference.   
In the Inner City populations not only do you not know what the patient is using but they themselves often don’t know.  That’s how fentanyl caught everyone by surprise. lt just appeared.  Patients have drug addiction, schizophrenia, manic depression, heart disease etc, may or may not be using what they are being prescribed, and on top of that are ingesting, by needle, mouth or smoke substances unknown to them or sometimes even their drug dealer.  

Dr. Cheryl Rowe, a truly compassionate psychiatrist,  presented this all so well.  Lindsay Windhager, a social worker, clarified just what patients encountered in their programs. The programs that had come about to meet the tremendous need of the community, grassroots movements and peer support coupled with medical and government resources..  

Dr. Cheryl Rowe said quite succinctly that there were no CANMAT guidelines really for her population . Esvery case had it’s own unique flavour and had to be dealt with on an individual basis guided by experience and relationship.  Some of the relationships had taken years to develop.  Cooperation and trust were hard won.  
Dr. Quastrel emphasized the need for clear diagnosis.  He challenged the idea of ‘dual diagnosis’ as in the rest of medicine it is common for patients to have multiple diagnosis.  He said clearly, psychiatrists especially, had to be willing to treat their patients addictions if they were going to continue to work in psychiatry . So many psychiatric patients have addictions.  I was so thankful to hear this marvellous man.   I know many thorough concientiouspsychiatrists who are truly comprehensive as Dr. Quastrel was.  However it is not uncommon to encounter a cavalier negligent sort who simply doesn't ask the questions and avoids knowing about their patients lives.  The patients call them the prescription pad doctors, have no respect for them and just use them to get whatever med they want for whatever reason.  The trouble is, street drugs have interactions with psychiatric medications and side effects that can worsen common existing disease like Hep C.

I was thoroughly impressed with the presentation.  

I’d heard Dr. Rowe present previously so wasn’t surprised at the quality of her presentation.  She really is a caring and experienced clinician.  I do look forward to hearing more from Dr. Quastrel as his knowledge of medicine,  pharmacology and addictive substances was most impressive.  I really did enjoy his answer to the question how to manage the heroin addict with a co existing pulmonary embolism.  

So much of inner city populations are social work with issues of housing, disability, finances, access that it was central that Lindsay Winhager was there to emphasize the need for a team approach.
In the discussion that continued after the presentation was over I enjoyed seeing Dr. Stewart Wakeman, another Winnipeg psychiatrist known for his experience and compassion

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These are notes I took. As usual they are far less than was offered but give a jist of what was presented. I apologize for any errors or lapses.

What to use when your patient is using: choosing psychiatric medications for patients with concurrent disorders in an inner city populations

Cheryl Rowe, MD FRCPC
Adam Quastel, MD FRCPC
Lindsay Windhager, BSW

Inner City Health Associates

Seaton House
Sisterling drop in

Model we use
Housing First, Harm Reduction, Psychiattric Rehabilitation, Patient Centered, Recovery Oriented/Consumer

85 % of patients have concurrent psychiatric diagnosis
75% of patients have concurrent physical diagnosis (hep c, etc)

No CANMAT guidelines for us

Montreal put out CanMat guidelines for depression and Substance Use Disorders, but there was no level 1 or 2 evidence or even level 3

Concurrent Disorders - truama, adhd, psychosis, anxiety, ptsd, tbi, schizophrenia, bipolar, drug indusced.
heroin, crack alcohol crystal meth marijuan

Why use a medication at all - retention, symbol of good faith
Side-effects on brain/nervous system/cardiovascular, respiratory, liver and kidneys
street drug effects
ability to monitor the patient
OD potential
Daily or weekly dispensing
Cost of non insured

Sistering - 24/7 drop in for women and transpeople - began nov 2015

low barrier 
safe space for women
harm reduction

Lindsay Windhager MD
-community worker 
-street involved women
-sometimes sleeping outdoors
foster trust and build relationship
education and support
court advocacy and rights
how to use different services
harm reduction programs 
  • needle kits, make kits, dialogue
crisis support
tips and tricks on safest sex work
education re drugs like fentanyl
social and recreational programs

-very little stability
-pronounced long hx of trauma, sexual violence in street
-problems with trust
-women engaged in sex work
  • lost children to social services
-often involvement with justice system

Sistering result from grassroots advocacy demanding services for women

Open door approach 
Meet person where they are at
Develop programs with somen
Well established peer program
Try to be as accommodating as we can regarding behaviour
Being flexible

Emphasize social justice and rights of drug users

Crystal meth newer to our neck of the woods

Women have had a lot of negative experiences with medical services
closed doors and 
unable to wait in the clinical setting
not being in shape to attend medical care

At Sisterling we had partnership with other agency
Building relationship with IHCha - medical and psychiatric services

Adam Quastrel, MD FRCPC
St Michaels
Multi disciplinary team
Head of Addiction Team
Intensive Case for save addiction
Diverting people from heavy use of emergency and detox

Everyone of my clients is using continuously
Concurrent Disorders
Previously ‘Substance abuse and mental disorder’ program
I found this a misnomer - in all other areas of medicine ‘co morbidity’ is treated normally
Everyone with addiction is more likely to have addiction and those with mental illness are at greater risk for addiction
The barrier is psychiatrists who have not been trained to treat substance disorders

3 cases

52 single, no children on ODSP, living at Seaton House on an off for 14 years
used heroin and opiates on methadone 60 mg
smoke crack 4-5 per week
criminal record for theft
Hep c +ve , hypertension, COPD
-gets beaten up badly - concussions , 
multiple evicts
gr 8 , dx adhd
-mood swings, anxiety, can’t focus, anger, insomnia, multiple awakening, paranoia - being followed by police, hearing voices.

Polysubstance, ABI, Psychosis, ADD
-apply for housing
-case management
-family doctor
-neuro psych testing
(we have neuropsychologist at Seaton House)

wants treatment, sleep, anti anxiety, inability to focus, stop the voices
what to use for sleep
What to use for psychosis and voices - but has a head injury
-does he really have add
does he need  a mood stabilizer
what about crack use and drug interactions

-prazozin - ptsd 

Need Diagnosis 

what we did
mirtazepine 30 for sleep, anxiety and depression
abilify 5 mg for voices, paranoia and mood
Will consider atamoxetine
Daily dispense along with methadone

Sue - 1
42-4 children, apprehended by CAS, single homeless, sometimes in a shelter, supported by Ontario Works, no ID , lost health card
drinks 2-3 bottles of wine per night
has used crack and opiates - none in 3 years
smokes marijuana at night to sleep
depressed, anxious, panic attacks, poor sleep, nightmares, flashbacks to rape, can’t ride the subway 
sexually abused as a child, multiple abuse by male partners, sex trade workers, multiple charges of theft and fraud
hep c positive, fertile and no birth control, pas symptons, multiple STDs, HIV neg 4 years ago

She wants help with medical marijauna

Provisional dx  - alcohol dependency, ptsd, depression with anxiety attacks anxiety disorder
refer to family doctor
 get harm reduction counsellor/case manager
get ODSP
Apply for Housing
Refer to Trauma and Alcohol program (Jean Tweed) 

What we did
-es-citalopram 10 mg am
Trazadone 100 hs
lorazepam 1 mg od prn for anxiety dispense 7 per week
Think about use of naltrexone/topiramate/ or sertraline/naltrexone
-peer harm reduction support

Karen 1 
38 ye old woman with 12 year old daughter - apprehended 
gad, social avoidance, performance anxiety, poor concentration and focus, left school gr 8, dx add, given ritalin from 3 years at age 8

I want you to treat my add and anxiety

Polysubstance abuse-stimulants

What we did

Harm reduction support
self report adult add scale filled out
Ritalin 10 mg  am
pt refused ziprasidone and seroquel
added clonazepam at 2 pm and 8 pm

Would I do it again…..I’m not sure ….she got off clonazepam
She was seeing family doctor
Clonazepam did something for sleep, but found out she was taking the clonazepam 2 tabs at 10

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