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

relationship

Advocacy

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

Nonjudgemental

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

Psychiatrist 

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

ED-1

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

Options

-prazozin - ptsd 

Need Diagnosis 

Prioritize 

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

ADHD

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

Canadian Psychiatric Association 66th Annual Conference

I am truly enjoying this Canadian Psychiatric Association conference.  The last conference I attended in Vancouver I so enjoyed Dr. Trevor Hurwitz presentation but then I always enjoy Dr. Hurwitz and hear him frequently at UBC.
19 years ago I joined the International Doctors in AA and have really enjoyed the psychiatrists  and psychiatric presentations there. That was mostly because of the spirituality.    I'm also connected with the Christian Medical and Dental Association and truly enjoy the psychiatrists I've befriended there. I’ve attended the World Congress of Psychiatry and International Society of Addiction Medicine and various other conferences where psychiatry and psychiatrists congregate but I really feel I might have enjoyed attending more CPA.
The CPA Journal did get a new editor, with the result it stopped being a publishing place for academic psychologists and began again to be relevant to me as a psychiatrist.  Reading the journal more is how I read the notice of this meeting.   I’ve been a member of CPA for decades and haven’t felt I got nearly as much bang for the buck as I get from the Christian Medical and Dental Society, until now.
This  CPA conference  is truly outstanding. I am beginning to think my issue with CPA might have less to do with transference and more to do with counter transference.  It’s like that time in therapy where your realize the therapist really might have something more to offer.  I hate to think this is solely my aging and increased wisdom.  I've wanted to attend this CPA since first I saw the line up of topics and speakers.  There are just so many excellent clinically relevant,  valuable and timely presentations.
Having to be at Kingston Hospital yesterday for a family meeting,  I missed that day, sorry to have not been present to hear Sidney Kennedy on Major Depression. I’d really wanted to do the advanced motivational interviewing course as motivational interviewing is something I do a lot of in my DTES clinical work.There was a new Canadian ECT Standards presentation and as I’ve referred several patients with intractable depression for ECT with good results (it’s been 25 years since I’ve given it myself,).  I really thought this was b important for me to review.  There were also some courses on use of social media which is extremely important and relevant. Given the mess the DSMV made of Somatic Symptom Disorder I had also looked forward to hearing this expertly addressed.
Today’s presentations made up for Thursdays academic loss. Being with family,  knowing love first hand and seeing the excellence of clinicians and a wonderful care team in action at Kingston made today’s presentations all the more poignant.
Today I was delighted to attend the ABC of DBT, Applying Principles to the Care of Patients with Substance Use Disorders.  Having treated a former professor of dialectics and discussed DBT extensively in therapy I’d studied it in journals,  on line and seen the excellent research findings of it’s benefits for the SUD populations.  Ketan Vegda, and Wiplove Lamba were truly awesome.  Their presentation alone was worth the price of admission.
I absolutely loved their role play.  It made sense of the theoretical material they had presented very well.  Watching and listening to the role play I felt  that I’ve  ‘got it’ in a way I’d not untill then. Next week in my clinic I’ll be applying simple variations on my well honed eclectic approach to therapy with patients.  Now that’s not something that I can say happens often given years of psychoanalytic psychotherapy training, group psychotherapy training, focal therapy training, CBT training starting in the 80’s, motivational therapy training, former hypnosis training, family therapy training and 12 step facilitation therapy training.  The fact is these young guys really know their stuff. It’s now obvious why and how DBT works and why patients with SUD would appreciate it.  I even went out and bought the recommended text, DBT Skills Training, Handouts and Worksheets by Marsham M. Linehan.  It’s not the same old same old repackaged thing.
I’m skeptical of advances in my field since so much of psychology is ‘renaming’ the old things. One young ‘person’ in the audience commented on the feelings of the therapist in relationship to the patient and how she appreciated the comments about this. I couldn’t resist later saying, “we used to refer to that as ‘counter transference’.  An older woman beside her laughed. It wasn’t against the young person but rather in amusing at the two of us being older and from a different era.   Not that that’s bad.
It was amusing later listening to books and names being bandied about by younger colleagues.  I hoped they still knew Freud, Jung, Karen Horney, Seligman, Kohut, Kernberg.  I did feel though that the ‘pop stars’ of today are a generation beyond my own pantheon. The classics obviously remain but not the lesser stars.   The field is just so broad too today.   It's like my days of Elvis, the Beatles and Rolling Stones.  I remember looking at the line up of a local rock festival and realizing I didn’t know a single entertainer.  I’m still listening to the Guess Who.
I loved the booths and papers and lounge area.  I spent literally  an hour on two separate occasions talking to medication representatives, military forces personnel,  treatment centre personnel, recruiters, banking and insurance folk and regional representatives.  I go to trade shows these days, mostly to do with motorcycles and boats.  But I like to look at what’s being offered and sometimes really enjoy chatting with the folk there.   I always love meeting the Edgewood folk.  Interior BC Health and BC recruiters were terrific.  I love learning that Ability,  a medication I use  extensively in tablet form has come out with Ability Maintena, a monthly injectable form.   I didn’t even know about Latuda (Lurasidone hydrochloride) which is apparently much more used in Eastern Canada. It’s real attraction for me as an antipsychotic was the lack of QT complications.  The Pristiq rep showed me that Pristiq had few side effects than high dose effexor and was well tolerated when used with other meds. I also met the folks from the Medical Psychotherapy Association of Canada.  Having talked with them and learned about MDPAC, I really think this is a group I need to belong to.
Everyone loved the keynote speaker, Clara Hughes, Open Heart, Open Mind. There was a line up forever of folks, who having bought her book were happily waiting for an autograph.
The book selection provided by two sellers was awesome. I tend to down load e books mostly these days reading everything on my Ipad but even so I came away with a Medical Clinics of North America Travel and Adventure Medicine.  I used to attend those conferences when I was more focussed on off shore sailing, having sailed solo to Hawaii in winter.  I loved the whacky doctors I there, no psychiatrists stick out except some fellow who liked the places ‘above where helicopters go’. We related to how our work caused us to enjoy time in extreme wilderness.
I mostly like conferences for networking. I  talked to several psychiatrists I liked instantly.  There was a real international flavour to the conference with every colour of skin and a multitude of accents represented.
The Royal College of Physicians and Surgeons had a terrific young man answering questions about MOCOMP. I love MOCOMP and Mainport our continuing medical education service. I bored the young man with my pet peeve but really otherwise love MOCOMP.  He was there to present on the new ‘competency’ approach to following careers.  Given that Mainport is an excellent reflection of my ongoing study which I like as a journal, I think the very smart and creative folk at RCPS are going to keep astounding us. Who knows, they may address my libertarian pet peeve.  The engineers have rebelled and done a masterful job of facing the gun toting political bullies. I don’t mind recording my study as a professional but am questioning ‘administrators’ arrogance with their self serving money driven  ‘educational accreditation’ processes.  I will probably ‘forget’ to fill in some form about this CPA conference and some supercilious shit will object that I didn’t get my ‘attendance’ cosigned in triplicate. I remember I lead an insurrection against the hospital management wanting clinicians to use a ‘time clock’.  I think this is something I discussed at length in my psychoanalytic therapy in training years.
Unfortunately the Transcultural Psychiatry workshop I’d wanted to attend overlapped with the Chronic Pain, PTSD and TBI workshop I really felt I needed to attend.  So much of my work is specifically trauma,head injury and pain related.  I’m often called upon to be an expert witness and sometimes actually undertake that role voluntarily.  Zohar Waisman MD FRCPC and Adam Little LLB were incredible!  They did a role play with discussion by themselves and incorporating the audience.  Zohar, “performed” as doctor expert witness and Adam as lawyer in a case which had actually occurred.  The audience discussion and the points made and the nitty gritty of expert witness/clinician was humorously and pertinently discussed.  I commented later that their presentation had been so ‘like’ the 'real thing’ I was having ‘flashbacks’ of my own worst moments in court.  What a great presentation! Well worth attending the conference for the learning in that session alone.
I am pissed that I missed Susan Abbey and George Jarvis.  I even missed Harry Kaplinsky!  The CPA Conference is as  bad as going to an ice cream counter and having to choose.  I get Cherry Ice Cream but must forgo the Pistachio and Green Tea flavours. It’s not fair!.
I was also highly responsible and chose Advances in Diagnosis Treatment and Prevention of Dementia, not just because I personally need to know how to prevent it, but mostly because I’m seeing more elderly patients in my practice. Having thoroughly enjoyed the presentations of Tarek Rajji, Zahinoor Ismaiel, Amer Burhan and Sanjeev Kumar I feel more confidence, recognized a couple of mistakes I’ve made which I can address next week without harm to patient,  but now I mostly know where to turn.  I really am going to change my practice for the better.   I have answers to questions I’d had put to me by patients and family which I’d not been able to answer. Now I can.  I really liked the humanity of these fellows too. Yes they were researchers and published internationally accredited papers but it was clear that they cared for people.
So that was the day.  Tomorrow I have a whole day more of really great psychiatry learning. They’re even going to feed me at a Thing called the President’s Gala. This Westin Harbour Castle Hotel in Toronto is really fine too.  I love my view of the Harbour. Now that my sailboat is in these fresh waters I can imagine one day anchoring somewhere out there. I see an island and wonder if it’s the same one where I was swimming as a teenager and participated in rescuing a drowning woman.  Toronto is a favourite city with so many memories for me. Another reason I was glad to come to CPA.  2017 the Conference is in Ottawa. As so many close family are there, I believe I’ll be attending the CPA again.  I’m really enjoying this conference.