Prayer and Jesus

Luke 18
1.“Then Jesus told his disciples a parable to show them they should always pray and not give up.
2.He said, “In a certain town there was a judge who neither feared God nor cared what people thought.
3. And there was a widow in that town who kept coming to him with the plea, “Grant me justice against my adversary.”
4. “For some time he refused. But finally he said to himself, “Even though I don’t fear God or care what people think
5. yet because this widow keeps bothering me, I will see that she gets justice,
so that she won’t eventually come back and attack me!"
6. And the Lord said, “Listen to what the unjust judges says.
7. And will not God bring about justice for his chosen ones, who cry out to him day and night? Will he keep putting them off?
8. I tell you, he will see that they get justice , and quickly. However when the Son of Man comes, will he find faith on the earth?"

I am again being falsely accused. I am troubled that the courts in Canada have become like the Communist inviting  false witnesses to give power to the State and cause every truthful man or women to live in fear. Totalitarian and police states encourage all to report on their neighbours and celebrate those most those who lie and attack Christians and good and true officials.
I cry night and day “Grant me justice against my adversary”.  But I struggle to understand if my adversary is the individual psychopath or psychotic or the system that does not protect good men who do their work.
There are untold odious complaints and false testimonies against doctors who work with two types of patients
1) those with drug and alcohol problems.  If any one knows drug addicts or alcoholic they know well what vengeful and petty individuals they can be when they are in their cups or hung over.  The Big Book of Alcoholics Anonymous based on the honest assessment of their individuals in recovery noted that Resentment and Fear were central features of their universally immature character.  Resentment was the central fuel of their addiction.  Bitterness.  They commonly live in the past and hold grudges and their fear of retaliation is such that they are often paranoid for periods of time.  These are the people who are quick to complaint, easily offended, don’t like to cut anyone slack but demand it for themselves.  They fill the courts and their letters to the editor are endless. They are the cause of many wars ever waiting to restart some old conflict in the hope of getting even.
2) those who are involved are dissatisfied with their employer and are getting paid to stay home from work by an insurance company.. Their anger with their employer is more often concerning deep seated issues against authority tied to their earliest childhood, neglectful or outright abusive parents.  The doctor is called upon to write a letter to say that they cannot work because of some condition.  With physical medicine this isn’t as threatening for the doctor because when the injury heals there is obvious evidence that the patient is well so return to work should follow.  There are objective measures.  In psychiatry the issue is far far worse because the complaints are invariably about something ‘subjective’ such as “pain”, “dizziness”, “fatigue”, “depression”,  “anxiety”.  With Borderlines Personality Disorders, like Paranoid Personality Disorders, people are seen in black and white categories. Lawyers who defend people against sometimes callous insensitive greedy insurance companies are often as as difficult as insurance company companies who are occasionally callous insensitive and greedy.  There is a conflict inherent in this situation made worse by the inexperience or agendas of the lawyers and the insurance agents. The psychiatrist who is required by law to be as ‘objective’ and ‘impartial’ as possible is called upon to express an ‘opinion’.  The psychiatrist is however by ethical oath an ‘advocate’ for the patient.  He can not lie but he will be as supportive and understanding of her concern as possible.  To this end I report the patients concerns clearly and measure their subjective complains and write formulations that attempt to see the best in people, some of whom are malingering sociopaths.  I “diagnosed’ sociopaths and malingerers by the dozens in the past but I was told that this was unacceptable and really it was now a matter for the courts and judge to assess this. Further if I stated the obvious that a person was a sociopath,psycopath or malingerer in my opinion the patient would definitely complain to the College of Physicians who might well agree but punish me to the tune of $10,000 tying me up in a legal beaurocratic malaise that gave them raison d’être and made them and lawyers rich but definitively punished me to no end.  I have been punished repeated to the cost of hundreds of thousands of dollars for telling the truth as a doctor.
So I don’t diagnose people as sociopaths, psychopaths or malingerers anymore.  Naturally it’s like any doctor who is told that he cannot diagnose ‘appendicitis’ or some such not uncommon diagnosis in their field.  Our textbooks and diagnositic formulations all include these diagnosis but ‘smart’ doctors especially those most interested in ‘business’ just know not to diagnose anything that would be ‘unpopular’ with patients. Rich doctors must be liked and popular. It was for this reason and it continues to a lesser extent that most doctors won’t diagnose alcoholism, addiction or even sometimes mental illness.  They don’t want to lose the patient.
Regardless today I support patients and generally don’t think of them as psychopaths , sociopaths or malingerers because as their doctor I really want to ‘give them the benefit of the doubt’. Even when I learn they are unable to work because it’s too tough for them to sit at a desk for 2 hours because of their pain but they fly 12 hours to vacation spots and back, well it does seem suspicious but I am there to be helpful not to be a judge. The judge will sort this out because so often in these cases too the insurance company will hire a psychiatrist who will quickly see how ‘incongruent’ the patients statements are and even note that while the patient can’t do ‘their’ job they are nonetheless working under the table or doing things for family and friends which would constitute work.  One person who ‘couldn’t work’ had a family business running out of the basement. Anyone who has worked with insurance companies knows just how sadly common this is especially in those who do not share an ethical or moral basis  of the greater community.
When patients are angry with doctors because the doctor is perceived as a threat they don’t complain about the doctor specifically being a threat to their desire to get their‘ money for nothing’  because of deep seated issues of entitlement but rather will make their complaint ‘powerful’ as possible.  Single male doctors are therefore with women always ‘sexually harassing’ simply because there is no basis to ‘sexual harassment’ except a he said, she said complaint much like the subjective complain of ‘fatigue’.  One female theif who called her accuser ‘sexually harassing’ actually called the policeman who investigated ‘sexually harassing’ and the Vancouver police department would not follow up on the case because of the fear and cost of this complaint to date to their members.  In all cases there is no ‘objectivity’ to the complaint but it remains as a ‘character assassination’ and it’s done for profit as the patient in these work place issues is trying to get ‘money for nothing’ and ‘time off work’.
Many companies have successfully reduced these kinds of situations by allowing workers to be off work in a company club house or cafeteria but not allowing them to go home to be paid.  One of the sure signs of malingering or alternatively factitious disorder is the refusal of patients to attend group therapy or any group situation because when there is a group malingerers sociopaths and psychopaths know that their ‘sickness behaviour’ might be filmed or witnessed by others when they are not aware. In one to one interviews it’s easy to maintain the ‘sham’ but in the group process there are just too many variables and even a person with a decided limp might forget to do it in the complexity of groups. Naturally Insurance companies when they believe a person is a sociopath , psychopath or malingerer will want the person with the psycihaitric illness to attend a group. Further group therapy is to psychiatrists the very best of therapy and a central cornerstone of psychiatric hospitalization.  There is really little reason for a person not to attend group therapy.
Yet this is when the ‘I’m agoraphobic and I’m social phobic ‘ or “I’m too fatigued to get out of bed” . In the past they were hospitlized at this point and the ‘truth would out’ . One of my patients couldn’t ‘walk’ , but the nurse noted that he sneaked out of his bed at night to use the washroom so I diagnosed him as a ‘malingerer’ and naturally he complained to the authorities , right up to the Minister of Health, that I was a Fascist.  I miss the hospital as it was the very best psychiatric intervention for sorting this matter out.
Without hospital resources psychiatrists are now at increased threat and risk from dangerous patients.
Further in Canada there is a horrendous unconscionable lack of consequence for PERJURY.  The 10 Commandments says “Thou shalt not Bear False Witness’ but in this anti Christian, anti Bible, Anti Truth, Anti doctor country I have been utterly utterly frustrated and countless times in tears for doing my job and trying to help patients to the best of my ability with all my training and experience but only to be faced with complaints because I continue to work with people who have drug and alcohol problems and who are out of work and in conflict with their insurance companies..
The sad thing is that I have been able to help hundreds or thousands of people and the proverbial ‘bad’ apple is one in a hundred.  Most of my patients who have anxiety or pain or depression offered ‘group therapy’ jump at the opportunity. Patients who want to get better will do everything to so and yet there are those for whom treatments don’t work but they don’t pick and chose and refuse to be in any situation where they are under observation.  They welcome a chance to prove their truthfulness.
Patients with drug and alcohol problems are harmed by those who lie and enable their disease. I make the diagnosis as frankly as I do cancer. Being diagnosed with alcoholism or addiction is like being told you have cancer but if doctors don’t tell their patients the truth they patients are at greater risk.
I never think of patients as the adversary.  I thinks the system or the authorities are at fault because they know these aren’t ‘isolated’ cases yet they punish the doctors who work with these difficult groups. Most of my much smarter and more clever and more business oriented colleagues simply say no to seeing patients with drug and alcohol problems or work problems or with superego lacunae.  I see people who are murderers and prostitutes and often very dangerous and often very unclean and smelling very badly and I know my colleagues and the government in general denies them care by neglect or a countless series of barriers to treatment but I work with these people but I get upset, forgive me jesus, for being stabbed in the back over and over again by the very people who are supposed to be serving the same people I am.
I am not the enemy.
I am a Christian who when I was going to work in Africa was told by Dr. Jack Hildes Canada has as many people who are need missionary doctors because our health care services don’t treat the marginalized.  I have followed his advise and worked in the areas of ‘greatest need’ but I’m old and tired and reduced to crying by my bedside where my mother taught me to pray on my knees.
GOD GRANT ME JUSTICE AGAINST MY ADVERSARIES.

Addiction Medicine and Occupation Medicine

The Interface of Addiction Medicine and Occupational Medicine

-your patient’s safety in the workplace

Sept. 27, 2013

Dr. Paul Sobey

Dr. Paul Farnam

Presentation from the Canadian Society of Addiction Medicine Annual Meeting, Vancouver, BC 2013.  These are two amazing clinicians with excellent training and impressive clinical experience.  The presentation was fully attended and highly appreciated. I hope my rough notes will give a sense of the depth and breadth of information available.

Learning objections

-safety issues

-potential negative impact

-duty to notify

Employer and employee responsibilites

Guideliness

In US there’s a major omnibus bill and occupational medicine is a huge industry

In Canada less legislative issues - more decided by precedent

Definitions

Risk sensitive

-safety critical

-safety sensitive or person of public trust

 Health Professions Act

www.health.gov.bc.ca/professional-regulation/

Who is subject?

Duty to Report - Section 32.2 and 32.3

-32 (2) (1) A registrant must report in writing - reasonable and probable grounds, believes that the contued practiced of a designated health profession might constitute a danger to the public

32 (3) (1) - admission to a hospital or a private hospital as defined in the Hospital Act , for psychiatric care or treatment, or treatment for addiction to alcohol or drugs the other person is unable to practice

Employers are worried

• Substance Use Disorders don’t stop at the gate
• illicit drugs
• -Also alcohol , marijuana and prescription drugs
• problems with attendance, performance

Worksafe BC 

4.20 Impairment by alcohol, drug or other substance

“a person must not enter or remain at any workplace while the person’s ability to work is affected by alcohol, a drug or other substance”

“the employer must not knowlingly permit a person to remain at anyworkplace while the person is impaired”

Substances and Diagnosis

-medications

-opioids

-medical marijuana

-benzodiazepine

-methadone and suboxone

Issues when SSP use of these medications 

Suspicion or clear evidence

Opioids

Canada - world’s second largest per capita consumer of prescription opioids

-750 mg/year/person of morphine (2010)

Risk sensitive fitness considerations

-no addiction disorder

• addiction diagnosis = increased complexity
• may not be a candidate for COT
  Chronic stable, reasonable dose with b3nefit
• literature supported diagnosis
• psychiatric and medical issues in remission

Medical Marijuana

-this is a huge conundrum

-from occupational consideration it’s not approved

Marijuana is not a medication

Not HPB approved

• like all other medications

Medical Marijunaa Access Act

-I don’t havea clue what the exemption looks like

-approve usages may exclude occupying a Safety Sensitive Position

Benzodiazepines

-pam and z drugs

-limitted research and prescribing data

-memory and other cogntive impairment

-rarely primary drug of choice

-in background - predictive of other subtance abuse?

-alcohol and opioids problem

high rate of abuse in OAT population

-withdrawal compicates treatment

When I’m doing a withdrawal will the withdrawal period exclude them from work

Methadone and Bup?Nal

Chronic Cancer and Noncancer Pain

-methadone only

-means failure of typical opioids

-There fore must question fitness for work

Oipoid Agonist Therapy (OAT)

-Means Opioid Dependence

-All patients are ‘polydrug dependent’

Take Homes 

-a valid prescription does not mean “no impairment’

-no valid prescription does mean impairment

Is the medical conditions related to their having a Safety Sensitive Position

Failure to progress or loss of level of function

What would a panel of my peers say?

Dr. Paul Farnum

Healthquest Occupational Health Corporation

Alliance Medical Monitoring

For 7 years directed physician health program of BC - “that was an interesting population”

Workplace and Addiction

Progressive worsening in work - identification then intervention then comprehensive assessment - primary treatment - “after care” - Medical Monitoring - Return to work 

Employer 

“Identification” - Attendance, performance, behaviour

-Safety

• the employer is getting becoming aware
• Intervention “the difficult conversation”
• Occupational-Addiction Medicine Assessment
• Comprehensive “Independent” assessment
• Biopsychosocialspiritual assessment
• -biological testing, collateral information, ‘understanding job demands’

Addicted MDs - what di we learn?

-need good assessment and good treatment

“using comprehensive monitoring, coordinated by an experienced Physician Health Program, reports demonstrate that over 70% of addicted physicians achieve five years of sobriety, are able to return to work and resume a functional lifestyle”

Medical Monitoring

“Relapse Prevention Agreement”

Between patient and experienced Monitor

Duration - 2 years/5 years /indefinite

No mood altering potentially addictve drugs

Approved recovery activities eg Mutual Support Meetings (AA/NA, SMART etc)

Unscheduled Lab work (Urine/Blood/Saliva/Hair)

Regular contact with monitor

Regular Reporting to “Oversight body”

Contingency Behavioural Management

-ties compliance to benefits (employment) through accountability

-contingency -if you don’t follow thorugh - job on line

Safety Sensitive RTW considerations

-Safe and Sustainable Return to Work

-Comprehensibel Occ/Add Evaluation

-recommended primary treatment 

Re-evaluation for fitness to work

-stable remission, enough for occupation

-workplace consideraation - restrictions, limitations

-accomodations required

Commuynicating with the employer

as patient’s md you are their advocate

As IME assessor or MRO you act independently

-know who you are communicating with and ask about the employer’s procedures

-no occupational health department

-fitness to work considearation only

Employer and employee responsibilities

• emploeyer - duty to accomodate disability
• -recognised medical condition
• -how far does it extend
• -no duty to accomodate employee with ‘abuse’
• Employee and Union - duty to facilitate the accomodation

Duty to Accomodate

-Fraser Lake Sawmills - Hybrid Approach - defining case

may be degree of ‘non culpableness”  or hybrid or culpable

Treatment Resistance and “Last Chance Agreements”

Key Messages

Safety, safety, safety

Understand Standard of CAre - ‘stable abstinent remission’

-Understand guidelines and employer’s rights

Don’t treat and keep secret!