Addiction, Alcohollism and Motivation to Change

Daily Reflections Dec. 21

Listen Share and Pray

‘When working with a man and his family, you should take care not to participate in their quarrels.  You may spoil you chance of being helpful if you do. »

When trying to help a fellow alcoholic, I’ve given in to an impulse to give advice, and perhaps that’s inevitable .  But allowing others the right to be wrong reaps its own benefits.  The best I can do ….and it sounds easier that it is put into practice….is to listen, share personal experiences, and pray for others. 

I remember well meaning individuals offering kind suggestions.  The difficulty is that they didn’t realize the depth of betrayal I’d experience of myself and with others. I simply did’t trust. I trusted God but those closest to me had abused my trust.  I was at that point quite frankly paranoid.  In the sense that schizophrenics are delusional because of the depth of their anxiety and alienation so are addicts and alcoholics however they appear normal at times and can hide the insaniety brewing beneath the surface.  

Motivational therapy is the treatment of choice today for addition. It first says listen. It says identify the ‘stage of change’ the addict or alcoholic is at .  The first stage is « precontemptlation’.  In precontemplation stage the individual is in such depth of denial they reject even the suggestion of a problem and become angry with anyone or any discussion of their ‘problem’.  Their problem is ‘you’.  They don’t see any reason to change, The problem is that others need to change.  Others need to cut them some slack, get off their backs, quit bugging them.  Others are the problem, not them.

Contemplation phase is different. In this phase the person might accept there is a problem and they might even consider they may be doing something wrong. They may think they drink too much or that drugs aren’t helping.  They aren’t ready to change but they are open minded enough to consider the possibility that their best friend and solutions, drugs and alcohol and those who use them might no longer be helpful.  Before Prochaska and others studied Motivation it was found that government funding and intervention immensely wasted and counterproductive because it was aimed at those in ‘precontemplation phase’.  This only entrenched alcoholics and addicts against change.  The timing of intervention is critical in addiction and when the person shows openness to the idea of their use of alcohol and drugs being part of the problem that’s the time when it’s good to simply off solutions.  Persons’ in the ‘contemplation phase’ welcome being given ‘literature’, ‘invited to come to a meeting’, offered a phone number, advised where rehab and detox centres are.  They are like people who say they were thinking of having their house painted so don’t mind hearing what’s out there but don’t want anything onerous or involved.  Just offer them information and be prepared to follow up at some time.,

Determination is a critical time and distinguished by the person admitting they have a problem and committing to making a change This is like the smoker who says they need to quit smoking and say they’re going to fo it in the spring.  This is the time to offer time and resources to assist the person in getting to the next and most critical phase. Unfortunately many alcoholic and addicts with talk ad infinitum about needing to quit and planning to quit but the rubber never seems to touch the road.  When it does that’s the time to pull out the stops.  In the past those who cared had wasted endless energy on those in the precontemplation phase they were angry by the time the person actually was determining to make a change.  Listening carefully to the alcoholic or addict is the key to identifying the fundamental changes

The Action Phase is evidenced not by talk but by action.  The key statement that came out of the AA experience was ‘if you talk the talk, walk the walk’.  Action is evidenced by a number key actions.  The first was attending a meeting of AA. Today people can attend a meeting of SMART or any of the faith based and secular ‘group therapy’ meetings. The corner stone of therapy for addiction is the group.  Social anxiety is central to addiction along with shame and dishonesty.  When a person is actually in the action phase they will literally leave their basement, pub, crack house, drinking and drugging friends and join a group of people who have and are leaving the old world for the new.  These are the people who don’t just talk about exercise but actually go into the gym and buy a membership.  In the action they admit they have a problem and need help.  Other major actions are going to a clinician and saying they have a problem with addiction or alcoholism and asking for help.  There’s going to a Detox centre. The action is picking up the phone or going to the building and asking for help. There’s calling the rehab centre and speaking to intake and then attending. 

This is where resources need to be focussed because this is what the person is truly ready and making an effort to change.  

The success of treatment for alcoholism and addiction is truly amazing if the person had a job and family in tact.  Too commonly people have looked at addicts that are homeless and on the street and not seen the success of treatment because of these few individuals who have end stage disease.  It would be like saying cancer can’t be cured.  Every day cancers are being cured if caught early.  Countless skin cancer and cervical cancer and breast cancer and even lung cancers and brain cancers are cured routinely because they are caught early and treatment is initiated.  In the past early diagnoses and treatment wasn’t available and people avoided seeking help for a lot of medical conditions, many of the worst known, because we screen for them and treat them early.  Pilots and doctors have a 90% success rate in treatment of alcoholism and addiction because their conditions are recognised early and treatment is initiated. 

The Gold Standard Navy pilot program involved 30 day in patient treatment followed by 3 AA meetings a week and monthly meeting with a psychiatrist and counselling as needed resulting in 80 to 85% of pilots remaining sober and clean and flying 5 years later.

That’s like the success with early detection and treatment for Tuberculosis and Diabetes. These used to be lethal diseases and still have major complications at end stage but the life expectancy in the past was at 20 to 30 years but now is 60 to 70 years. Alcoholics used to die 10 to 30 years younger but now are living out their lives.  Heart disease, lung disease, liver disease, hypertension and various cancers were all often caused by addiction and alcoholism but now are recognised as treatable life style diseases.  The longevity research show now that the greatest thing individuals can do to improve the length and quality of their lives is simply to quit drinking and smoking.  

People change,  Addiction and alcoholism are diseases that are curable.  Abstinence is the treatment of choice and AA remains a cornerstone of long terms success.  Not surprisingly it was called the ‘miracle of the 20th century’ because prior to the 1930’s alcoholism and addiction were a deadly scourge akin to the various infections that were treated by the introduction of sulfa and penicillin.  

Today we also have ‘harm reduction’ therapies for those in the determination phase of change but still ambivalent about abstinence.  I liken them to those who are told that surgery is the solution to their hip disease but want to do physiotherapy and exercise first.  If that works great.  In medicine clinicians want success and realize that scientifically there are superior treatments so that we describe efficacy of therapy as ‘primary’ , ‘secondary’ and tertiary.  

Because of the insaniety associated with addiction and compulsion and obsession often an addict will think that if only they don’t use heroin in the afternoon and limit their use to the morning all will be well.  It’s important for others to listen and not argue but to explain what indeed has been proven to be effective in the same way as we’d not agree with a dying man that using a salve on his bullet would will be sufficient.  We would recommend taking the bullet out and treating the would with antibiotics instead.  Of course if he wants to try his salve and lotion first that’s okay.  Insurance companies and governments and jobs won’t usually support these subjectively appealing but objectively questionable solutions yet it never helps to ‘argue’ with insanity.  

I prefer to pray myself.  

Recovery: Whose job is it?

Big Book of Alcoholics Anonymous

“You will be most successful with alcoholics if you do not exhibit any passion for crusade or reform. Never talk down to an alcoholic from any moral or spiritual hilltop, simply lay out the kit of spiritual tools for his inspection.””

Commentary

When we are teaching junior doctors and counsellors we advise them to watch themselves carefully to see if they are putting more effort than the patient into ‘rescuing or curing’ them.  Whose job is it?  I can’t make a person drink the medicine. I can give them the medicine.  Indeed it’s been said that I will hold their head under the water to make them drink but that after a while even with that approach even some would drown rather than drink.

Addiction is in part a pout.  Enablers are treating alcoholics and adults like children when they are adults.  Perhaps proto adult,  Adolescent really, but to be adult you don’t start ‘babying them’ for their own good. You offer them resources to ‘recover’, not to persist in their addiction.

I remember hearing these two addicts discussing social services, “I’ve now got a place, there’s free meals at the church, and I’ve got a bus pass, now all my disability money can go to drugs.’  

Giving money to an addict is actually giving money to his dealer.  One of the most successful ‘harm reduction’ policies which worked for years until some aetheist interfered, was a local priest who took checks from addicts on Welfare Wednesday check day, then doled their money back to them daily. I have a patient whose sister gives her brother $10 a day because when he had $20 he spent it on crack. His dealer actually approached him each day to ask if he had $20.

Adulthood is ‘accountability’.  

The brain disease of addiction is that it causes the forebrain or judgement to be impaired. A person loses the capacity for ‘delayed gratification’.

 “I want it all and I want it now.”

There is a regression from adulthood back to adolescent learning.  In recovery we describe the person as "40 going on 15." It seems there’s an emotional delay that occurs once a person becomes addicted. Most people learn to ‘self soothe’ without drugs and alcohol. The alcoholic or addict may act juvenile but they’re always very canny.  Their capacity to think is not impaired in that sense. The fatal flaw is their inability to carry through with plans.  They have all the ideas of the ‘adolescent’ or ‘child’ but lack the capacity to complete tasks, overcome adversity, work together, delay gratification.  These are all adult skills.  Drugs disrupt learning 'adulting'.

I treat mechanical brain injury, when a person drives a motorcycle into the wall hitting their head and chemical brain injury, when a person dumps drugs and alcohol on the chemical circuit board of the brain.  The behaviour and function are very similiar though fortunately for the alcoholic and addict initially the damage is reversible if they abstain.  The recovery process are the same.

In ‘detox’ treatment, empirically it was necessary to establish a barrier if only slight to access.  Years ago when I was heading a detox we would admit a person who while drinking had remorse and wanted to ‘go on the wagon’.  As the drugs cleared their system they ‘changed their mind’ and left. Today most detox require a person to be seeking detox for 24 to 48 hours. The success is greater.  The greater the commitment the greater the success. Even with Suboxone a person must be in ‘withdrawal’ before the treatment can begin. If this medication which is a combination of opiate and antagonist was given to a person ‘high’ it would just throw them into painful withdrawal.  

The treatment of choice for addiction and alcoholism is abstinence.  Harm reduction has always been considered a valid ‘stepping stone’ or ‘entry’ point to recovery.  Recovery is the whole ‘process’.     

When you feel you’re doing more work at their recovery than they are, it’s time to back off.  Alcoholism and addiction are in part escapism. The adult with every drink becomes more childlike, seeking the tit or womb.  They become legless and incompetent.

With an injured person in the emergency we as doctors provide immediate care and take over the function for the person in the first day but even if we put them on respirators and bypass machines we are always working to get them off.

The survival post surgery is best in those who get up and walk on their own.  Why would we think differently in treating mental illnesss. The aim is to restore a person to full functioning. Yet there are enablers and those who ‘appear’ to care. but are really negative not believing in the possibility of recovery for an individual.  They are the enablers who infanticize the alcoholic or addict and provide them everything.

I wonder when I see what my mechanical brain injured patient is given versus the chemical brain injured person. When the latter is getting ‘more’ something is wrong.  The recovery from mechanical brain injury, if severe, still can occur but it’s slow. Fortunately the person isn’t continuing to hit themselves in the head with a hammer like the addict who continues to relapse.

If they  are alcoholic or addict continues to drink especially then we are the problem not them. We are enabling them to do more brain injury and more destruction.  Limit setting is adulting.

Unfortunately as children mirror adults, addicts and alcoholics mirror their caregivers.  When caregivers are unable to set limits, have rules, be themselves disciplined in their ‘giving’, then the addict or alcoholic doesn’t learn. As a life guard my first lesson was not to let the drowning person pull me down with them.

The original AA members when they went out to talk to an active alcoholic found that if they went alone they were as likely to start drinking again themselves.

We’ve seen many of the institutions established in good faith to help alcoholics and addicts take on the emotional maturity and behavioural developmental stages of the alcoholics and addicts.  The institution is pulled down by the drowning alcoholic and addict.  

There are caregivers and victims.

The joke in the church was that it should be called ‘sinners anonymous’. It was also said that we should not  ‘judge’ another because they ‘sinned’ differently.

It was found in Al Anon, the organization for friends and family of alcoholics, that ‘enabling’ and engaging in the ‘self delusions’ of alcoholics,’arguing with them’ , ‘coercing’ them etc was counter productive.  The Al Anon learned instead to ‘detach with love.’

The “holier than thou’ approach to addiction simply doesn’t work. The ‘I am the doctor, you are the patient’ doesn’t work either. What has worked quite miraculously is the approach of “I’ve had your problem" and "I’ve got a little further ahead while I’m still working on a problem.”

I asked a doctor how he had climbed Mount Everest and he told me that there was a club in Switzerland where people who had climbed Mount Everest gathered. He’d gone and learned from them.12 step programs have been similar clubs.  These are people who were spiritually bankrupt but now are rich on life. 

The job is not to ‘feed’ the alcoholic or addict for life’ but rather to ‘share the spiritual tools with those who want to learn and want recovery’.  The "Stages of Change" was developed by Prochaska to address the Motivational level of individuals who had various diseases.  As a caregiver one offers the ‘options’ and encourages ,but doesn’t do the work for the individual and doesn’t enable or ‘carry’ the person other than briefly.  

One of the problems with lack of resources in the area is that many ‘acute’ resources have been commandeered by the ‘chronic’ .  Hospital beds that are specially established as an ‘acute’ services are being used by mismanagment government for ‘chronic beds’.  Lack of chronic low cost housing results in losses of millions as the mismanaged constipated system backs up and high priced acute services are wasted on ‘chronic’ care.

Perhaps this is evidence that the ‘system’ and ‘institution’ has become more drunk or drug addicted or ‘diseased’ than those for who the service was intended.

IDAA 2019 Knoxville Tennessee, Part 2

It’s Sunday. I’m sitting in the Knoxville Market square.  I’ve just come from hearing Lori share her experience, strength and hope. She’s a humble heroine of the soul.  What an amazing story of hope,  growth and humor.  With epidemic suicide rates among doctors I’m so glad she found her way here.

 My personal nemesis has been sociopaths and psychotic people in power. I’ve fulfilled my contract, doing the best possible healing,  with the best training. I’ve served, reducing  “morbidly and mortality”, fighting disease and saving lives. 

Today that’s of little importance compared with ‘political correctness.’  Today,  the patient can die so long as the ‘chart’ lives. It’s all about spin and who you know. 

My police friend described her leaving the force saying, “I became a police woman to ‘fight crime’ . At the end end all I was allowed to do was ‘record’ crime’.  I feel like I joined the best hockey team in Canada. However today the  coach  only excelled in writing memos. Instead of firing coaches, doctors are required do more laps of the ice.

Lori’s challenges were family, sense of loss and betrayal traced back to childhood. I suspect my anti authority issue could relate to  being caned and strapped in school for ‘talking back’. 

 IDAA is always a time of deep reflection.  It’s not a place to ‘blame’ as much as I enjoy that. We discuss ‘choices’. 

In the psychiatry breakout meeting we talked of retirement, hearing among others, from my favourite retired psychiatrist,  his joy in welded art. Others talked of ways of winding down. Meanwhile the youngest heard  our stories and shared their own struggles with their new careers and their aspirations. 

It’s sadly the only place in the profession today that we talk openly and honestly without fear of retribution by the authorities or ‘loss of face’.  I attended the national medical meeting and enjoyed the didactic ‘fact’ lectures somewhat but felt so much ego. I was glad I’d worn my suit and tie. 

At IDAA most everyone wore shorts and Hawaiian shirts except for the banquets. The girls looked great in sun dresses. The ladies were so elegant. The group cleaned up well. Every conference there’s a thousand present plus or minus a hundred or so. Some 40,000 plus are active members. 

Saturday night banquet Merve gave the most succinct and moving banquet speech. He described his journey of recovery as a series of interventions  of divine and human love. He ended his extraordinarily miraculous talk with a quote from the Doobie Brother’s “Without love where would we be now?” “Without Love where would we be now!”. 

Of course,it was a medical conferenece too. That day I’d attended a terrific CME discussing reward centers, the amygdala, nucleus accumbens, the pre frontal cortex, and effects of dopamine and oxytocin. which drugs did specifically what. We even learned the genetic codes associated with predisposition to alcoholism. 

The Friday CME was especially good. I loved Dr. Michael Baron’s talk, Prescribing and Pain. In Tennessee the doctors prescribing opiates must attend two hours of CME on addiction and opiates. I was privileged to attend this, truly appreciating the combination of neuroscience , public health and common sense presented. 

Abstinence remains the treatment of choice  but Dr. Bill Haning's talk, Cultural Aspects of Addiction,  on Culture of Addiction emphasized that treatment  isn’t just stopping a substance but involves significant life changes to prevent relapse. The work addressed in this CME was about harm reduction and abstinence.  The speaker talked of the great benefits of AA fellowship but also discussed a variety of groups which also help. 

Having dealt with so much grief, such mind numbing, debilitating, heart rending sadness , I simply enjoyed the  Dr Jes Montgomery's talk on grief and recovery. It was healing personally and certainly gave me tools to help with patients.

Our small group discussion of illnesss and recovery, dealing with pain without opiates, avoiding relapse when opiates were needed post surgery, was highly informative.  I’d thought this group of doctors who were so good looking and smart were immune and immortal.  We all discussed  various illness we’d had and various treatments. .One had just had surgery. I’d had a dental implant. Another had arthritis.  It’s one thing to read  the textbooks some of which were written by people in the room, but a whole other thing to hear what people actually did.  

As a psychiatrist we learn about the ‘self’ , the false self, the ego, and  ‘persona’ . Quite frankly IDAA is the only place I really get to talk with other physicians,but especially psychiatrists. The other docs and specialists say it’s the same them..  I loved my colleague from a small town saying this was the only time he’d spoken truthfully and meaningfully with another psychiatrist in ‘years’.  

Training as an analytic psychotherapist  I’d early enjoyed bearing my soul and gaining  useful insights . But here it was even better because I knew that the psychiatrist I was sharing with had been divorced like me. No one claimed to have the answers here. No one was holier that thou. I just love the lack of hypocrisy. There certainly wasn’t any pomposity which seems to thrive elsewhere. 

Dick didn’t pretend he didn’t have feel pain walking. Cheryl didn’t conceal her love and concern. No one was just ‘fine’ (that’s an acronym which ‘fucked inside, nice exterior’ ).  Everyone’s hurting sometime. But here everyone knew that and also also shared their love and their joy. 

I heard the most wonderful stories of trips, travels, children and grandchildren, recovery and successes in work.I was so pleased my young Canadian friend was now on the national board. Several other docs I knew had completed fellowships, while others had become heads of programs and hospitals. 

Through the year I read about the ‘greats’ in our fields who I meet here.  World renown plastic surgeons and cardiologists with the rankest sense of humor continue to inspire me.  The most beautiful brilliant elegant ladies talking intimately about their disease and finally asking for help touch my inner being. I laugh and tear up more in these days than I do all year.

It was also so moving to be among the many there with incredibly long term marriages.  What examples these 30, 40 and 50 year married doctors provided. My friends Art and Carole have 53 years together but seem like high school sweethearts.  

I loved seeing Adam and Corinne when Corinne celebrated the Jerry Moe program sharing what it meant for her son. I loved seeing the Jerry Moe kids and the outrageous teens.  The babies and toddlers there represented hope and faith in the flesh.  

Overall I felt again I’d entered an adult learning place  of genius and creativity beyond the limited world of bean counters and administration that saw health care as commodity. I was able to discuss difficult patients and changes in treatment over coffee and in  hall way consults.  

The whole relevance of ‘sign in’ CME came up for discussion in our little group where the actual definition of a professional was so reminiscent of what I’d signed up for. “I learn from a patient. If someone comes in with something I don’t know, that triggers my research and consultation.  I don’t pay attention to all this other stuff that does’t apply to me and my area of work.”  The anesthesiologist shared.

That was exactly what I thought.   I will never forget administrative doctor shouting ‘doctors should never learn from patients’ they’re there to teach the patients’. By contrast,  at times over coffee,  it seemed like a ‘barter market’. I was sharing psychiatry jewels I’d been bequeathed to get in return dermatology pearls. This is the  way ‘adult professionals’ learn. But then we wondered if this only worked because we were in this IDAA bubble where it was okay to be to not know everything’, to be vulnerable, and to share. I joked about sitting at the ‘in table’ with Art and Dick and Graeme.  

It was fun to be at IDAA.  I emailed a friend who I hope to see at next year’s high school reunion saying, “IDAA  iwas like being at a doctors ‘ elementary school reunion’ . It could only be better if Jerry Moe and the kids let’s us join their program. All that was missing was the dance with the mirrored balls hanging from the ceiling.

Next year it’s Spokane. IDAA2020 Spokane.

I love the town of Spokane and already know some brilliant psychiatrists there.  I’m thinking of riding my Harley down and certainly wearing boxers even if they do ride up my ass.  I’m all signed up.  IDAA is like the love story “same time next year’.  

I know I’d never have been able to stay a doctor and especially a psychiatrist without IDAA.  I might not even be alive.  I certainly wouldn’t have this life beyond my wildest dreams.  I may not have the spaceship I want but I can truly say with the deepest gratitude I’ve had times of being rocketed into the fourth dimension.  I can’t wait to read the cyberdoc on line discussions (and gossip)  in the coming weeks.  I love hearing  Hugh, Nathan,  Zeke and Dave . I actually talked to two doctors Saturday  who had been to Antatica. One who worked there and the other wanted to see penguins. There’s something about belong to a group of doctors with characters like that.

God bless.

. 

Harm Reduction Good; Harm Reduction Bad

Harm Reduction Treatment is a term which is used commonly in Addiction Medicine. It followed “abstinence based’ treatment.  In other areas of medicine the term ‘palliative care’ is an equivalent expression.

The positive aspect of “Harm Reduction’ was that it provided care specifically for those who were not ready to embrace ‘abstinence based’ treatment or for those who had failed, even repeatedly failed, conventional abstinence based therapies.  

Historically ‘abstinence based’ therapy for alcoholism was exemplified by the Gold Standard , Navy Pilot program. Navy pilots cost millions to train and flew jets worth even more millions.  When they developed addiction as they did, grounding them caused  a major loss, often involving suicide, while letting them fly, was obviously dangerous. The treatment which followed included a 30 day inpatient treatment, followed by 3 meetings a week of AA (Alcoholics Anonymous), weekly drug and alcohol counselling and monthly visits to see a psychiatrist. At 5 years 80% of pilots were abstinent and flying.  A major success.  

This treatment with some variations is the treatment principally used for judges, doctors, other professionals, union members and all those ‘contributing citizens’ who individually or by insurance can afford the ‘best’.  It is well known by the advocacy of such distinquished treatment programs as Betty Ford, Talbot, Homewood, Edgewood, Orchard etc.  Often patients begin with a period of detox and follow up today can include SMART, a cognitive behavioural group therapy.  Group therapy is the cornerstone of abstinence based therapy.  A fundamental principle of addiction treatment in this model is that substance abuse compensates for relationship deficits.  Accountability and support come through fellowship and community.  Isolation begets addiction, participation treats addiction.

By contrast Harm Reduction Treatment has tended towards maintaining the substance use with a view to control. Originally the World Health Organization validated the Harm Reduction Programs only as they ‘lead to abstinence’. Abstinence is the ‘cure’ per se for addiction.  To this end methadone, suboxone, Kadian and now Heroin are used as Opiate Replacement Therapy.  Eventually patients were weaned off opiates however where in the abstinence models this occurred in weeks, in the Harm Reduction Model this might well take years.  

Alcohol is provided in a controlled fashion on the hour for chronic alcoholics, maintaining the steady state alcohol level and avoiding withdrawal as well as the revolving door detox, hospital and jail scenarios.

There is no doubt that harm reduction is good Community Medicine. 30 years ago when I was doing a Community Medicine Residency I studied the Swiss Methadone Maintenance programs of the day, showing then as they do today, that providing methadone, reduces the spread of diseases associated with needles, like infections, most importantly hepatitis and HIV.  They also dramatically reduce the cost of revolving door hospital, detox and jail scenarios. The legal cost alone for the theft associated with heroin use is horrendous and methadone simply dramatically reduces this.  

Harm Reduction Treatment is very good for the community when it is approached responsibly and it’s fiscal benefits are understood.

 Locally the Portland Hotel Society was a scandal with all manner of corruption and devastating failure as their Harm Reduction Model became dominated by crime and a ‘better living through chemistry’ attitude which indeed promoted drug abuse as opposed to treating it. The Portland Hotel Society has since modified it’s approach. 

For individuals as opposed to the community, harm reduction can be very good.  Methadone and suboxone specifically impressively reduce the use of needles and help individuals get free from the life of servitude supporting the criminal drug dealer factions and associated crime.  Eventually patients who might otherwise have died often have the time to move on to abstinence based therapies.  When the patients come for methadone or suboxone their other physical and mental health needs can be addressed.  Otherwise they might well avoid health care.  Housing, food, health care are all available as part of the a good methadone program.  Certainly we encourage participation and provided biopsychosocial interventions to the patients on methadone. The College of Physicians and Surgeons of BC like other College programs across Canada and similarly in other civilized first world countries,  historically managed the methadone programs and encouraged they take a wholistic approach to the patient.  Opiate programs required a federal government waiver given that the laws against drugs like heroin were nation wide. Locally the addiction treatment has been transferred mostly to Province or State and University care. 

Harm Reduction Therapy could well be seen as bad if all the doctor was doing was being a ‘drug pusher for the multinationals’ rather than using motivation therapy,   12 step facilitation therapy and cognitive behaviour therapy to move patients along the spectrum of motivation to change as laid out by Prochaska.  The preventative medicine aim was through relationship therapy with the physician , psychiatrist, pharmacist and overall treatment team aiming to ensure the patient’s self esteem and health indices  improved.  These indeed do and for many individuals the methadone and suboxone treatment have been life saving.  Heroin and other ‘needle maintenance programs’ are early ‘add ons’ whose value is not nearly as evident given that the key feature of methadone was that it moved patients off needles with the community risk inherent to methadone or suboxone, oral medications.

The alcohol therapy has been an end stage treatment model for chronic alcoholics who have failed all other programs and whose lives are more manageable without the drunk then withdrawal roller coaster broken by relationship with health care and managed hourly alcohol intake.

Champix  and bupropion, nicotine replacement gums and patches, and vapes are all Harm Reduction Therapies which have had proven success in helping people become abstinent for nicotine and smoking.

Revia (naltrexone) is a medication which reduces craving for alcohol and empirically reduces alcohol intake in those who abuse.  Acamprosate is another such medication. 

Narcan kits which reverse overdose are definitely a harm reduction strategy especially when put into the hands of first responders.  They are a simple preventative medicine strategy for those of my patients who I encourage to have on hand when they are using with family or friends trained to know how to use them. 

The safe injection site is obviously another  harm reduction strategy.

Needle Exchange programs are proven harm reduction therapy where the patient exchanges a dirty needle for a clean needle. Unfortunately locally the needle exchange program devolved into a ‘free needle’ program with needles being tossed out of a basket in the local park. 

A variety of medications have been used along with diets to treat obesity and overeating, sometimes call food addiction. At the extreme, when behavioural change fails, surgical interventions such as stomach stapling have been long acknowledged as life saving.

So why is Harm Reduction Bad?  Obviously it isn’t of itself.  Reducing harm is good and the use of this marketing term is very seductive indeed. Unfortunately it can be ‘enabling’ and can cause the disease to persist given the huge element of denial involved in addiction.  Further the Harm Reduction Therapies tend to be pharmaceutical or medicalized  and costly compared to the low cost equivalence of the more labour intensive approaches of treatment centres and frankly almost cost free community support programs.  Often all the high cost and front end approaches are used and use up the patients resources while in the end the recommendation is to continue in AA/NA or SMART as this is a chronic disease process and unfortunately the real issue is prevention of relapse.

When patients have work and family and community relationships still in tact they are most likely to benefit and succeed with the conventional abstinence based programs, detox, treatment centre, and group therapy. In traditional medicine this is considered the ‘primary’ care model and harm reduction therapy is considered ‘secondary’ or ‘tertiary care’.

Harm Reduction becomes ‘bad’ when judges and doctors and the wealthy are given the abstinence based approach while the poor are ‘maintained’ on their drugs without giving them the opportunity of ‘cure’ which comes with abstinence based models.

Further, the harm reduction models can contain an inherent negation of the patient’s capacity to change.  Seminal studies have shown that a patients capacity to change and get well depends strongly on the therapists belief in their capacity to do so.   If the therapist doesn’t believe the patient can overcome their addiction to heroin the therapist will indeed prove to be the rate limiting step. The success of AA and NA is that the rooms are simply full of individuals who have indeed climbed the Mount Everest of Recovery and encourage others to believe they too can succeed.  

Both models have their naysayers and both models have their glorious success stories. The social justice warriors often argue that the addict and alcoholic should have ‘free’ stuff , in this case ‘free drugs’.  Unfortunately the disease of addiction is one of ‘more’ and there simply isn’t enough of whatever to suit the active alcoholic or addict who will die or commit crimes to persist in his or her narcissistic hedonistic pursuits.  

Should society pay to increase the risk to itself.  Part of the difficulty today is that there are increasing numbers of those who feel society should allow them to ‘spread their disease’ , a group of HIV positive individuals having parties with ‘non infected’ but those seeking “solidarity”.  

In the best of possible worlds when physicians, psychiatrists and other care givers are seeking what is best for the patients ,understanding the severity of the disease, the limits of resources and looking at each case individually there is rarely any conflict between the models .as in the individual’s life and care both models are at different times and sometimes together  being used.  

Politically, Harm Reduction Therapy has, I believe, a great deal more potential for harm than traditional abstinence based therapies.  Naturally there is a concern that the rise in addiction and death has been parallel to the increase in Harm Reduction Programs. Is this an association or is some of this cause and effect.  Changing the ‘drug dealer’ from the street criminal to the State has sent a different message. Legitimizing drug and alcohol abuse can be problematic.  Promoting marijuana use for profit just like promoting alcohol for profit may cost individuals and communities while a few profit.  

What is best for the individual, what is best for the community and what is best for the State and treating services are great when they all work together. Historically, the individual has been lost in the demands of community and State and those that ‘profit’ from individuals with disabilities such as addiction.  

We have always done ‘Harm Reduction’ as doctors. My concern has principally been individuals get the best care. The group “Like Minded Doctors” developed in part to discuss these concerns. 

21 years

I remember looking forward to drinking legally. 21 years of age was being an adult. Celebrating being an adult was going into a pub and ordering a beer without fear.  Drinking legally was being a man.

Then the provinces of Canada between 1968 to 1970  dropped the legal age of drinking from 21 to 18 or 19.  I felt short changed. I had sneaked into bars mostly to hear bands and be with older friends in bands but somehow when the age changed it meant that the ‘rite of passage’ somehow changed with it.  I developed a resentment.  One day I was drinking illegally, next legally, but what I’d missed is that great 21 year old party bash.  Life wasn’t fair. 

Now I’m 21 again.  Old enough to drink in my own era of thought. Ironically 21 now is the number of years I’ve not drunk. I could drink today too but I choose not to. Today like most days I pray I won’t. 

It’s a long fast.  It’s a sacrifice of the first born most desired pleasure for greater joy here and in heaven. It’s not drinking really I feel this way about but smoking. I miss smoking.  I felt a man when I had a pipe or cigar in my mouth more than when I had a pint. Indeed I quit drinking as much to quit smoking as for any reason. I was addicted to smoking and had quit three times each time starting again while I was drinking.  In retrospect I saw that most of the really rotten things I had in my life were somehow related to the drinking and the way it effected my judgment at the time or for days after. 

The last time I quit both. Smoking was bad and even evil in my mind by then, drinking not so bad.  Man was never meant to inhale smoke of any kind. We were not born with chimneys. I kidded myself the menthol was good for me. I even thought pot was good, because it was a ‘herb’ but while I could have eaten cookies or made tea I instead smoked that too. I even hot knifed hash in the east.  Hash was an east coast thing. Marijuana was a west coast thing.  Crystal meth used to be a European thing while Cocaine and crack dominated the west. Now it’s all fentanyl. I consider myself lucky I got out before cocaine and crack and crystal meth and heroin and fentanyl became prevalent. 

I think with some humility and gratitude that if I’d not quit smoking I might well have smoked crack.  Today I’d smoke fentanyl.  So many dead There but for the grace of God go I. 

I don’t miss the feeling of swimming vision, spinning rooms, the ‘not caring’ how people perceived me as I was a happy fool drinking. I don’t miss brushing people off.  Smoking I was interested in the inhaling and exhaling like a pranayama guru would be with air. But I didn’t appreciate the air and I didn’t appreciate the water. I liked them corrupted then.  Today I’m thankful for breathing. I breathe some days like it’s the best thing in the world. I’ll catch myself not breathing or shallow breathing and take a great big breath smelling the scents and fragrances and thanking my lucky stars to be alive. I love clear spring water alone, love feeling the coolness in my throat, enlivened rather than depressed.  Alcohol is a depressant. 

We say luck is God acting anonymously. I really feel lucky or rather loved by God, just to be alive when I consider where it could have gone.  We’re to celebrate God with ‘praise and thanksgiving’.  We become closer to God with fasting.  Sacrifices were not of the throw away kind but of the best. Hence the story of the man who was going to give up his child and was told not to. By contrast to the Biblical tradition other religions of a more barbaric age were sacrificing their children for prosperity.  There’s a difference between giving old used socks or new socks as a gift to someone. I get that.  

A pastoral friend commented on my life and wondered if giving up alcohol would be good for him. I had to tell him that for him he’d have to give up money. I could tell he didn’t like smoking or drinking but he really got excited around money.  Getting sober didn’t mean I gained a whole lot of subtlety or sensitivity.  I felt for a moment after my reply my friend was going to hit me.  

There’s an idea of ‘attachment’.   What attaches us to the physical or lower plane versus the world of thought, love and soul. Fasting reminds me that I’m a ‘spiritual being living in a material body’ rather than a ‘material being in a spiritual body’.

It was also clear to me that while smoking was physically unhealthy alcohol and those I drank alcohol with were no longer  people who helped me be the best person I could be. That’s what true friends are. Increasingly my drinking buddies were just that.  It had begun as fun.  We were living a great life when we were teenagers and couldn’t drink.  I didn’t smoke as a teen either.  I loved the athletics and scholarship, the music, and fellowship. The coffeehouses really were a blast. I still love coffee. But alcohol creeped into the scene.  At first it was a little something that was added to the already great event, the champagne with the celebration. Then I remember not wanting to stay at a dance because there was no booze. I loved to dance but finally dancing without alcohol didn’t seem as much fun.  Then everything I was doing socially and recreationally was associated with alcohol.  I even stopped to get a pack of cigarettes for after sex.  

I wasn’t alone.  It was the society I lived in.  Teaching at the university I was just one of the gang. I didn’t drink more or less than the next guy yet I had this whole moral thing going on. I was meditating and praying. I’d been attending church since I was a kid. I really believed in this idea of choosing between walking upright or slithering on the ground.  Sometimes drinking I really was legless.  Smoking is simply a death cult thing. It’s not life giving or life enhancing but self destructive, slow suicide. 

It seemed to that so many of my friends who had children changed. I didn’t drink more than a couple of drinks on call. I was on call 24/7 for a decade in a row. So I was what was called the ‘binge drinker’.  I’d get drunk on holidays. Studying I’d hardly drink until after the exams when I’d get thoroughly gassed.  People would comment on my dancing on tables but I danced on tables more sober than I ever did drunk. I was a dancer.  I had drunken friends who never danced, academic Ichabod Cranes, who’d try to dance on tables when we were drinking, monkey see, monkey do but they’d fall and I wouldn’t. 

 Often I thought that I was giving other people a ‘handicap’ by being a little drunk and stoned.  Not blatto but definitely one kite to the wind.  I’d think then that you probably shouldn’t drink, being stupid, or whatever, but you should thank me for drinking and giving you a chance to appear intelligent or athletic.  Only when I was drinking would I perceive myself in ‘competition’ without others. Sober I saw myself in competition with myself and my last achievement but drinking I’d compare.  There’s a special kind of egotism with drinking. I identified. I really was an egomaniac with an inferiority complex when I drank.  Sober, no.  When I smoked dope I just sat in the corner and stared a lot.  I liked music more stoned.  I was a slow lover and even fell asleep and had a partner fall asleep. Not quite like the movies. 

I took up knotting to have something to do with my hands. Smoking a pipe had to be a whole lot about the rituals and stopped me from biting my fingernails. I bite my fingernails again now.  But smoking caused me to wheeze. I also lost some of my sense of smell and taste. It’s always amuses me to hear smokers and drinkers going on about palate and taste, like blind men talking about the movie. Drinking does a lot of tissue damage, of the liver for sure, but also the heart and eventually is a serious cause of dementia. 

Quitting smoking the first thing I noticed was all the smells. I coughed up a bunch of lung for weeks then I breathed like a child again. St. Francis called his body, Brother Ass or Brother Donkey. Well when you give up smoking your body is happy.  I remember the first time I booked a motel room and didn’t ask for not smoking and was literally assailed by the stink and reek of old tobacco.  I smelt like that.  I smell the old men and women who are homeless but have enough money to smoke. They smell like ash trays. But just like me, they don’t know it. And I was wearing a Brook Brothers suit and fine cotton shirt, reeking.

Drinking I was losing a lot of time.  One or two glasses of wine are fine but when I got to three or four I wasn’t really at the top of my game. It’s why we don’t want pilots to be drunk and why Frank Zappa didn’t want people drunk or stoned in the studio. It’s non productive time.  I found when I stopped drinking I suddenly had a whole bunch more creative and useful time on my hands. I also found that I really didn’t like hanging around the conversations that went on when people got to drinking. I hate to use the word boring but that pretty much sums up what I thought pretty soon after.  Suddenly I was taking courses at the university after work, working out and writing seriously again.  I was reading a whole level higher of books. I always read but once again I was reading scientific texts, ancient tombs and studying other languages to appreciate translations.  

It all could have gone the other way.  There but for the grace of God go I.  These years have been good, exciting, interesting, useful, good friendship, wonderful dogs and memorable. I don’t forget like I used to.  My memories have a crispness and colour where as I remember them diluted and blurry.  No wonder we joke if you remember the 60’s and 70’s you probably weren’t there.

I’m here today. 21 years later. I love the learning and the friends.  It’s been a journey. I don’t think I’ll drink or smoke today. It’s hard not to some days with the government pushers working overtime.  I liked when a guy asked what is the difference between the government and any other gang. The answer was they’re not into selling children for sex, yet. Small mercies. They’re head over heels into pushing cigarettes, alcohol, gambling and now drugs.  

I was vulnerable as a young man.  My family was good, really good. Hard working,  law abiding, church going. They didn’t drink or smoke. Nothing they taught me was anything but good when I look back. Wise and fun.  I just had this anti authority thing going.  I didn’t know it then but I was afraid.  Everyone said the world was going to end.  Nuclear war, Silent Spring, Ozone Layer, Millenial Computer Crash.  It was just constant and if the world was going to end then ‘shananananana live for today.’  Be happy.  Get drunk. Party.  Carpe Diem. That bar at the end of the universe. 

But the world didn’t end.  And all around people were making families and building lives and those that drank and did drugs weren’t. I was fortunate. I got off the downhill spiral real early.  I remember being called a ‘high bottom’ and thinking these guy inviting me to join them were gay.  But by then I’d figured out that the elevator only went up or down , live or die, and I had to get off the down elevator. My partner had got hooked on coke and wouldn’t get help.  I thought I just loved the wild ones and bad ones but later learned that I had come to prefer ‘lower companions’ because it was a cheap way of making myself look good.  I’d moved away from the stirling friends, those I admired most. I’d been blessed to have the finest associations but one day I looked up and was surrounded by people who might be academics but they were drinking academics, they might be sailors, but they were the drinking sailors.  Suddenly the commonality of association was no longer the ‘best’, a true ‘meritocracy’ but rather a ‘tribal’ association.  Today I like to think my associations are the best and some even smoke or drink but no more than moderately or occasionally.  

I stil have some friends from that era too.  I like the ones who got off the merry go round.  I regained friends from before and I’ve made such very good friends since.  I’ll forever miss George and his poetry and stories.  We often laughed going to churches, dinners and meetings together, how we’d never have met if we’d not gone to the ‘bad boys’ club.  

I really am blessed.  So much is perception.  I’ve been able to study the mind and help people whose lives were in knots and who were on the verge of killing themselves. I think of ‘straightening paths’.  I’ve been able to reduce suffering and comfort people and restore people to work and family with the help of my training, my teachers and God.  It’s been a wonderful journey. I’m situated where I’ve been able to to help hundreds of people get out of the hole they dug from themselves and go off to find a new direction.  I think a lot about my parents and family and feel that in their eyes and the eyes of friends and even my dog and the cat I’m okay today.  I didn’t feel good about myself back then even though to the external world I was riding high, outwardly a true success story. Inwardly it was a different story.  

I never imagined I’d be here this long. I didn’t think I’d live this long. I’m thankful I am.  Now I could have a drink especially at my age, but really I don’t think I will. It’s like the apple in the garden. I’ve tasted it.  But I don’t want any more.  I can have anything else in the garden, even the apple but not both.  I could have a smoke too but why.  It does no good.   Truthfully, now,  I just want to walk with my Father.    

Fentanyl Epidemic

“I’m a doctor just like you,” he said.  I knew him in passing.  A good fellow.  Well intentioned. Most of his life a drug addict.  Now he and a friend like two teen agers going fishing patrolled the Downtown Eastside with Narcan kits they got free from the pharmacy.  Instead of trout he caught life slipping away in the gutters. Occasionally, he brought it back with drama and flourish.
“I’ve saved a dozen lives,” he said.
It was good entertainment. He used himself. The suboxone helped him and only a few times a week did he ‘party’.
 “We like the fentanyl because it’s strong enough we can push through the suboxone.” he said.  The patients liked the oral methadone and suboxone because it stopped the withdrawal sickness.  They could have a life separate from the daily grind of finding the money and getting high.
Their faces linger in my memory.  Only weeks ago I saw them.  A couple of young Caucasian women, in their 20’s with boyfriends.  They came as couples to get their opiate replacement medication.
I talk up a storm about AA/NA/SMART, the non pharmacological treatment groups, Detox and Treatment Centres and Recovery Homes..  We really only get paid for the prescriptions. The doctors break into two groups. The rich ones who write a lot of prescriptions and the poorer ones like me who do counselling and try each time to push the patients closer to recovery.
Recovery isn’t Harm Reduction.  Recovery is a proactive program of wellness leading to abstinence from mood altering substances.  Harm reduction is supposed to be a step on the way. But now our Prime Minister is so vocal about smoking pot and all the tobacco company wealth is back in the business of smoke everyone in the DTES is either smoking marijuana or cigarettes or both.  The trouble with drug addiction is that it really dulls the senses and their addiction to smoke is seen as nothing compared to the heroin and crystal meth and crack cocaine.  Then there’s the sex addiction, gambling and pornography and crime.  It’s a smorgasbord of free choice in the DTES.
But mostly they tell me they don’t want God or any of that spiritual or religious stuff.  They want drugs.  Addicts are materialist hedonists.  They are sometimes even like the monkeys we studied back in school with the electrodes in their amygdala pleasure centre who would live to pull the lever of pleasure.
More and more they tell me they don't want any of the recovery options. "I just want that free heroin. Can you direct me to where I can get my injections for free.  I don't want to stop using. I just want to get the stuff free."
Each of the women was demure with whimsical smiles and street smart eyes. College drop out. They’d been into opiates only for a year or two at most. They’d started with pills they got at parties and then became hooked. With their boyfriends they now needed fentanyl pills every day, at least one or two, sometimes more. They ground up the pills and snorted them.  They smoked marijuana too.  A lot of the marijuana had been sprinkled with fentanyl so the herb was hurting folk bad.  Even the organic shops marijuana had been tested and come back positive for fentanyl. I imagined with the fentanyl so cheap dealers were going about sprinkling powder here and there to increase their clientele.
Drug dealers are lizards who want to be your friend.
The Fentanyl was coming from China.  It was sold on line and brought in over the border en mass.  My hypochondriac patients complain that it and crystal meth are in the air in the DTES.  The paranoids are afraid of the food outside in the markets. They’re crazy but no more so than the neighbourhood.
It’s just that their faces linger. The two women from last month. I've mostly forgotten the patients that died before them.
Sometimes I remember Gordon Lightfoots song, “Only a go go girl in love with someone who doesn’t care.”  I think of their mothers.
They’re dead now.
Their boyfriends each on different weeks came in and told me the same story.
“We got high together and overdosed.  I woke up but she didn’t”.
They were sad but it hadn’t changed their own drug habit.  If anything they did more.  Running from the demons. Burying the pain.
“Sometimes you see the shadows out of the corner of your eye,’ the older guys tell me.
I talk about higher power and participation.  I repeat till the cows come home that it’s a disease of relationship and that they have to find a way to associate with people that don’t use.  I hand out pamphlets and point them to all the different groups and services that we have.  The government pays for drug and alcohol counsellors but it’s like getting adolescent boys out of gangs, one on one care doesn’t work. They need a new group, a new club, a new association.  Their religion is addiction. They see their drug as god and their dealer as their priest.  It’s high ritual.  The language doesn't tell you that but it's there as bold as the body bags.
I ask him if he’s stopped using.
“Not yet. “ he says telling me about the great feeling saving a life gives him with his free narcan kits.  I think of it as band aids.  It’s like a lone medic in Afghanistan. Every life counts.  Don Quixote charges another wind mill.  There has to be a Dulcinea.
I expect the feminists would call me chauvinist because I remember those two women more than the half dozen more young men I’ve known who are just as dead in these last few months.  It’s wrong to even speak of gender. Freedom of speech is dying as quickly as youth.  It's only okay to speak of what we're told to speak.  Designated truth or fake news.  More illusion of choice. There are so many divisions today.  I worry I’ll offend someone even by asking them to live. The Prime Minister is proud of his new physician assisted suicide programs.  They’re opening more and more needle injection sites with dilaudid and some are even giving free heroin.
They once assisted the Tong, Euro Gangs and Hell’s Angels who brought in the Heroin profiting by the government taking care of providing drug clubs, keeping their business alive with safe injection sites  and carrying all the costs of bad drugs.  Now they’re actually going toe to toe with pharmaceutical grade product versus the ‘shit they call down’, the gangs provide.
“It’s not heroin anymore.  It’s not been for a long time. Synthetic shit. That’s why the fentanyl is attractive. Cheaper and it does the trick better.” he said.
The uppers go with the downers.  Jib, or crystal meth is everywhere as well. Not as much crack smoking as doing jib these days.  There’s a lot of doing jib then heroin to get to sleep and then getting onto straight heroin and maybe cigarettes or pot. After the drugs get happening big time the alcohol which may or may not have been there in the beginning becomes less important.  Some say drugs account for 80 or 90% of the material theft.  The insurance companies are not suffering.
Legalization which is what our Prime Minister was pushing means that a drug could be sold in a school candy machine. If it’s legal, it’s legal. Like mother’s milk.
Decriminalization is accepting the disease model and treating the whole matter not as a moral issue but rather as an epidemic.  Harm Reduction, really palliative care, a term with a marketing twist came out of the cancer treatment and then the Aids Epidemic.
Harm reduction may not be that good for the individual. Individuals do best if they get into AA or NA , treatment, recovery houses or join a church.  When they look at people 20 years abstinent individually they mostly work,  belong to spiritual organizations and have replaced their previous habit with community participation and love.  Love of God, love of family, love of fellow man and woman.  Drug addiction is at best mental masturbation.
The Harm Reduction is good public health and ultimately may be preventative as the profit in drug sales moves into the public purse. It’s hard to say if there’s any less gambling today but the government gets the money rather than the Mafia.  Now one then wonders what’s the difference between public sector crime and private sector crime.
But I’m a medic in D Day and the enemy in this case, the drug dealers, they don’t provide medics for their ‘side’.  I still think I'm on the good side. I just don't know some days if I'm doing righteous work or enabling.  There’s a whole lot of other types of medicine I could do.  But I’m down here in the DTES with more and more young people. When I began in the 80's working in a detox the clientele was mostly in their 50's.  Not a lot of really old people in this work.  Living past 60 not so common here as in the suburbs.
My patient is going off with his buddy to look for more bodies in back alleys in hope he can revive them.
I’m just doing what doctors do, pushing life, where the profit always seems to be more in pushing death.

Avalon Recovery Society Tea and Fashion Show

The Avalon Recovery Society Tea and Fashion show took place again this year at the lovely Semiahmoo Fish and Game Club Hall. It was sold out.

Avalon Recovery Society started with 2 women in recovery deciding that what women in recovery needed was a safe place to go where they could feel good about themselves. It was a place where they would not have to worry about men but could focus on their own self image. They would be being with women who might be a few steps ahead of them on the road to health. Women in recovery helping women in recovery.
It would exist without government assistance so as to be free from politics and fads. It would be independent. The first Avalon drop in centre in West Vancouver. The atmosphere was of home away from home. Avalon Recovery Society became a huge success. That first centre in West Vancouver gave rise to another in Kerrisdale. White Rock has one and there’s another out east and more in development.
As an addiction psychiatrist I’ve been referring women with problems of alcoholism and addiction to Avalon Recovery Center for over a decade. There are AA meetings and other health oriented groups, such as yoga and meditation going on each day as well. There’s a hired staff person on site. It costs $400 a day to maintain one Avalon Centre. For so little money so many lives are saved.
My female patients have described the most positive experiences at Avalon. They have begun their road of recovery there. Often they are experiencing severe isolation in their homes and apartments, sometimes even homelessness before they begin the journey back to being contributing members of community. They especially speak of the safety they experience and the sisterhood of caring.
Cindy Faulkner Morrison welcomed everyone before Monica Marten gave the ‘word from the president’. Rhonda McJannet, after advanced training "herding cats for catwalks", continued to do her superb job as ‘fashion show coordinator’ with the beautiful and delightful models.
Today Dr. Ray Baker, one of Canada’s leading addiction medicine specialists, himself a long time supporter of Avalon, spoke of the oft times ‘hidden disease’ of addiction which women have. Commonly denying their history of abuse to caregivers and families they get misdiagnosed and take longer to get to the place where they can get the help they need.
Praveen P. told ‘my story’ an amazing tale of a phoenix rising from ashes of disease.

Constance Barnes, a leading political figure, and latest board member spoke of the importance of Avalon’s work with women.
The fashion show was splendid thanks to the Anna Kristina Boutique and Fashion on the Edge. My friend Laura loved so many of the outfits and lucked out winning a door prize gift certificate for a dress from one of the boutiques. . At the silent auction I got the tool set feeling very badly for outbidding some poor woman who will be cursing me when her car breaks down. Laura got more lotions. She waxed poetic about how  much she loves the Avalon Gala. “I always feel like a lady when I’m here." She loved the little tea finger sandwiches best.
It was a wonderful afternoon for such a worthy occasion. Envelopes were set out for donations. It felt good to support such a wonderful program. Avalon Recovery Society, what every neighbourhood needs.

How Much Methadone is Enough?

Methadone is used for 'pain control' and as a substitute therapy for opiate dependence. I'm only speaking to the latter today.
When a person starts a methadone maintenance program they may be using a wide range of compounds and dosages of pills, snorted heroin or injected heroin.  If one is 'new' to their opiate dependence there are detox programs and Narcotics Anonymous as alternatives which can be done alone or in combination with 1-3 month "treatment centres" followed by group living 'recovery homes' where drugs and alcohol are banned.
"New" usually means the person has been using regularly but not necessarily daily for less than a year or two.  When they are at the point of daily use and experiencing 'withdrawal' symptons without opiates they are 'dependent', and not just abusing drugs.  They're 'hooked'.
People who are early in their addiction where the amounts they use and the frequency of use is low may still benefit from methadone maintenance therapy but may also be good candidates for the alternative "substitution" therapy, Suboxone - a pill form combination of buprenorphine and naloxone.  Buprenorphine is the active opiate replacement medication while naloxone is the antagonist that makes the drug 'ineffective' if it is injected.
When a person comes into the Methadone Maintenance Program the normal dosage of medication that is used to 'start' regardless of the 'amount' of drug the person was using on the street is roughly 25 to 40 mg.  The concern of the methadone doctor is 'overdose'.  No doctor wants to 'kill' a patient to 'help' them. There is no way to know 'what' a person has been using on the street, since there is fluctuating purity of compounds and commonly dilutions.  It is understood that the 'starting' dosage is often not enough to stop the cravings and even other withdrawal symptons such as sweating, wide pupils etc. If a person has been injecting a whole lot of heroin this dosage of methadone may only take the 'edge' off.  People often take heroin in their early stage of starting methadone because they can't tolerate or wait for the right amount of methadone to be reached. The dosage of methadone is then increased every 5 to 10 days by the maximum amount of 10 mg to the dosage which is 'enough' for the individual patient.
The 'right' amount of methadone is that dosage which stops 'withdrawal symptons' and addresses specifically the 'physical' craving symptons.  The physical craving symptons are different from the 'psychological' craving. With psychologically craving all manner of expectations are associated with the 'getting high' or 'escape' the drug gives. A person knows they have reached the state of not having 'physical craving' when indeed the person is using methadone and if they try heroin say, "It doesn't work for me...it doesn't get me high anymore...it's wasting my money'.  The methadone at that point is blocking the opiate receptors.
Psychological craving is associated with the psychological aspects of peoples continued use of drugs past what they bodily "need."  Asked why they kept using some admittedly say "I had nothing else to do.... I was bored...... I thought I'd get higher..... I was lonely....The drugs were there.....  I just wanted to pass out. "  The psychological craving is part of the 'crazy' of drug doing. It's why overdose and death are common among heroin users.  Addiction is a deadly disease.
The World Health Organizations studies showed that people who were on at least 60 to 80 mg of methadone a day did better in the long run, staying in the programs, getting into Recovery, not relapsing to street heroin, than those using only 20 or 30 mg of heroin.  These are looking at large numbers. I have a couple of patients using less than 40 mg but their street use was low and infrequent. Further the lower dosage seems more likely a successful solution for those who snort rather than those who use IV heroin.  Suboxone may indeed be a better alternative overall for this group.  Others on low dose are slowly being tapered off,as they have done well on higher dosages, are off other drugs, have stable lives, may be back at work or school and generally are succeeding in the community.  This is when a patient may be on a slow taper but get to a very low dosage where it takes some time to come off 'the last little bit'.
Therefore anything under 100 mg of methadone can be consider standard or moderate dosage.  I have other patients on 220 mg and know of others on more. 200 mg is more in the 'high dosage' range. Patients who are on methadone for years, with 'clean urines', jobs and families, may over time need to increase or may decrease their methadone dosage. The dosage is a matter between the doctor and patient. It should never be 'judged' out of context.  Many of my patients who became 'hooked' on opiates following trauma who still have chronic pain but lost control of their prescription drug use for whatever reason, get back to normal lives on methadone maintenance but continue on the methadone for 'pain control' and just simply stay in the methadone maintenance programs. I have seen patients whose 'addiction' behaviourally was addressed years ago and they have been drug free and are living wholly normal lives in the community but continue to see the methadone maintenance doctors esssentially as they might see a 'pain specialist prescribing methadone'.
There are individuals who are 'rapid methadone metabolizers' and they need a higher dosage and may even need to have their methadone split to being administered twice a day.  To know if a person is a rapid metabolizer, the symptomatic picture is that the patient feels well immediately after but by evening or early morning is experiencing withdrawal. The doctor and the lab then do a series of blood level measurements after the methadone is taken to establish the peak and trough of the drug level and see when this is occuring. In rapid metabolizers the peak is the same as others but the trough occurs much more rapidly and remains low causing the patient the discomfort.  This may occasion a higher dosage than normal or splitting the methadone into two doses morning and evening.
Also crystal methamphetamine and cocaine will influence the subjective need for methadone as both are stimulants result in the patient physiologically or psychologically (or both) 'needing and wanting' more methadone to do the job. Commonly when patients stop their cocaine or crystal meth abuse their 'need' for methadone reduces drastically.
That said, some patients have other medications on board and if any are metabolized by the same system that metabolizes methadone or are associated with respiratory depression these have to be seriously considered. Benzodiazepines , (diazepam, clonazepam, lorazepam, etc) are all contraindicated in combination with methadone as the combination was the cause of death in sleep and overdose with methadone methadone maintenance programs. Indeed the prevailing wisdom to date as a result of  scientific evidence is that opiates and benzodiazpines are contraindicated together in general.
With all these considerations I asked Dr. G. Horvath, a leading authority on the clinical use of methadone, on how he would assess if a patient was on enough or too much methadone. Dr. Horvath is an addiction medicine specialist with a very extensive clinical experience in the Downtown Eastside Vancouver  where he has the Doc-Side Medical clinic in which a half dozen methadone doctors practice as well. As one doctor said, "he's seen it all'.  No one has but he's closer than most.
He wasn't terribly concerned about the 'dosage' even into the 200 range.
"If you are ever concerned about the dosage being too high, arrange with the pharmacist to know the actual time the medication was witnessed, then see the patient between 4 and 6 hours later. If they are not drowsy at that time then the dosage isn't too high. If you want to be even more scientific get a peak and trough level for the drug from the lab to ensure you're assessing their level of consciousness at the peak level of the drug. You can check the pupil size too."
This was extremely beneficial information to learn not just for the measurement of the 'dosage' in clinical practice,  but for me to answer questions from treatment centers,   therapists and others who have patients in mixed meetings where some of the people attending are on methadone and others are not.  Complaints sometimes arise that persons on methadone negatively affect meetings by being 'on the nod' and not able to 'participate'.  In the majority of cases I was asked about the individuals depressed state of consciousness was the consequence of benzodiazepines or other medications which the treating methadone doctor did not know about.
There are countless patients with legitimate pain legitimately on opiate medication attending advanced education and training without being obtunded and passing out in the classes.  When this is happening it should be seen as a red flag. Dosage of medication needs to be assessed with the prescribing doctor and  pharmacist and urine testing needs to be done to confirm that only methadone is being used.  The stat random urine test is best if a person appears too drowsy to participate and a person thinks their methadone level may be the cause. As I have said the most common cause is other drug abuse or use of other medications that the methadone doctor may not be aware of.  Most commonly the drowsiness in the cases I investigated was the excessive marijuana usage or benzodiazepine abuse or abuse of other opiates in addition to the methadone.
Here in Vancouver we have the benefit of an enlightened Minister of Health and pharmanet program which allows us to review easily what has been prescribed to an individual patient. Urine drug testing is a standard part of methadone maintenance programs and if there is a concern a "STAT" urine drug test can be ordered any time.
  However, in many other cases the methadone patient in the classroom who was nodding off was doing so because of poor sleep, sleep apnea, homelessness or even because the lecturer was utterly boring.  Many other explanations need to be considered.  Too often it is assumed that methadone or the 'dosage' of methadone is the issue.  Of course , sometimes it may be, but more often than not, that's not the case.
Commonly, the problem with a patient dropping out of methadone maintenance and returning to street heroin use is that the methadone dose isn't enough. There is a 'right' dosage which is specific to the individual.  That's when the Methadone Dosage is "enough".

Addiction Dialogues, Hillcrest Community Centre

The Hillcrest Community Centre host for the evening was very helpful and organized.  We had a large room upstairs  away from the busy but healthy pool and gym activities below.  We began as people were still coming in till it was finally a full house.
David Berner, radio host, actor, founder of X-Kalay Foundation for addiction, author of the recent book, All the Way home and group therapist at Orchard Treatment Centre on Bowen Island, was the moderator extraordinaire for the event.
Opening the panel was Counsellor Candace Plattor, author of Loving an Addict, Loving Yourself.  She spoke mostly to the effect of addiction on family and community. She described solutions for treatment incorporating choice and choices individual and family needed to make to avoid enabling.
Brenda Plante, Executive Director of Turning Point Recovery Society , spoke to the incredible success of their recovery home programs over that last 30 years. Brenda Plante is a household name in the recovery community of Vancouver for her big hearted, thoughtful but well managed programs. She has support from communities, neighbours, clients, governments, RCMP and all the doctors and counsellors working in addiction.   Already with houses in Richmond she's  just opened their newest house for women in North Vancouver.  She spoke of the program and the need for addicts to be reintegrated into life. Addiction is so isolating. It takes everything away. She encourages  people to become involved in groups,  clubs and various activities as part of their process of abstinence and recovery.
(I already have half a table of  tickets to the Turning Point's annual Gala. This year  Mathew Perry of the show "Friends"  is the keynote speaker.)
I, a physician, psychiatrist and addiction medicine specialist,  sat next to Brenda,  proud to be among such greats of the recovery community. I spoke mostly to the medical and psychiatric aspects of addiction, talking about genetics, liver, damage, lung damage, cancers caused, HIV and Hep C spread,  neurochemistry, harm reduction and medications, only being valid as they lead to abstinence and recovery. The 'cure' for addiction is abstinence.  (I did express my concern that there is a ‘customer’ model developing in the ‘harm reduction’ arena, with  conflict of interest, lack of faith and cynicism with increasingly two tiers of treatment, abstinence for the rich and educated and  harm reduction for the poor and less informed.  I spoke to the tremendous success of smoking cessation and how only 20 years ago this room might well have been filled with smokers and their accompanying clouds.  No better example could attest to the success of recovery. What is possible for cigarettes is equally possible for other drug addiction and alcoholism.  I mentioned Sabet's definitive book, Reefer Saniety, on the myths associated with marijuana.
AnnMarie McCullough began the first Recovery Day in Vancouver Canada. Now it’s spread throughout the provinces  so that it’s likely to be a national day perhaps as soon as  this year or next.  She also began Faces and Voices of Recovery while working at Orchard Treatment Centre. She spoke to the millions who are in recovery and the significance of their vote and political power. She was glad that the Health Minister, Terry Lake, provincially and Health Minister, Tony Clement, federally were so supportive of recovery. She encouraged everyone to speak to MP's and MLA’s and get involved like they were this evening, increasing  community awareness of the disease and need for treatment.  She spoke to the success of 12 step programs, other group therapies, treatment centres and recovery houses.
David shared a letter he’d received recently from a man, 35 years, clean and sober from drugs and alcohol, thanking him for believing in him in the days of  X-Kalay.
The audience participation began their with questions and answers.  Members from the Portland Society used this time to speak of  their controversial  provision of  alcohol for alcoholic and crack pipes for crack addicts. This lead to some interesting discussion.
A school teacher expressed his concern for the need for adolescent services.  Brenda Plante and Ann Marie spoke of the acute shortage of beds and other resources for adolescents.   Last Door Treatment Centre had however just opened some more  The need for adolescent services was a major concern to the audience.  I shared how Dr. Shimi Kang, an adolescent addiction psychiatrist was doing truly amazing work in the field.  (Our host  later told me he knew her and her husband personally and what a wonderful caring people they were.)
A tall man shared sadly how many friends of his had been killed by addiction. He spoke of Canadian solders who’d survived tours in Afghanistan only to come home to die in the clutches of drug addiction. He was very angry with  criminals invading every aspect of Canadian society with their "drug terrorism".
I couldn’t help remember  Sturges North motorcycle rally hearing  the great Canadian rock and roll band, Steppenwolf, singing their classic song, Goddam the Pusherman! I say, Goddam the Pusherman!
David thanked everyone for coming then individually we answered questions  speaking with people who told such tragic  stories of family members and friends  devastated by the disease of addiction.  A lovely woman was caring for the small children of her brother and wanted to know how to speak to the absences of addicted parents.
We were thanked all round.  Further Addiction Dialogues are planned.