Recovery Today

“I never thought I’d end up here.” She said. Her clothes were torn.  Not in that fashionable way. But a sleeping outside and not having anything else to change in torn and worn way.  Her hair was matted. There was dirt on her hands and face. She was white at one time.  “I graduated college.  I had a husband and a child before social services took my baby.  I don’t know where she is now.”

She’d been sleeping in front of the bank because there was an overhang there that kept some of the rain off her sleeping bag and newspaper shelter.

“I drank first but then it got to harder stuff. I needed the drugs.  I didn’t like what I did for them.  Drug dealers are all disgusting pigs.  But I didn’t have any money. “. She was crying, shoulders shaking.  She did’t smell fresh either.

I didnt’ know if this was true or just a tale she’d picked up and used.  The stories are passed around and reworked for most impact. Especially the stories of abuse. They’re so polished that I’ve even heard the lawyers down here repeating them as their own.  Jungle tales.  But she sounded real.  What was sad is how the last thing blamed was the drugs. First the parents, then the men or women or the job or even the banks and government but finally one day if they’re lucky they look in the mirror and say, “It’s me. It’s the drugs. My drug dealer isn’t my friend.” 

AA considered calling the Big Book, the truly classic recovery read, “The Way Out”.

So many who develop drug and alcohol abuse had trauma that many think the subsequent self destructive lives are ‘identification with the aggressor’ and Stockholm Syndrome.  No one doubts that it becomes a disease.  The brain changes.  The amygdala and hypothalamus are altered. DNA and neurotransmitters are all altered.  The very thinking is high jacked like a worm in a computer. Addiction can be followed by public health like a viral epidemic.  It spreads in poverty and war from carrier to target.  There are well established vectors.  The enablers are the most interesting group.  A twisted form of narcissism.  Dr. Scott Peck described them in “People of the Lie’.  Without the enablers the natural history of the disease would be brief.

“I ran out of money and no one wanted me. That ‘s why I came in.” He said. He’d been a teacher at one time. 

I first met them in the detox ward I supervised nearly 40 years ago.  Back then the Delirium Tremens of the alcoholics challenged me. I’d be up all night trying to keep the patients alive as they crashed about screaming and hallucinating and I’d be afraid of how much medication I gave them because they’d have liver disease, heart disease and lung disease from smoking and drinking. Mostly they were older men then.

Today’s it’s children. Nobody realizes how many beautiful young women are addicts today. Female alcoholism has passed that of men.  Red Red Wine.! Poor ME. Poor Me . Poor Me Another Drink! The guys are coming in younger too.  

40 years ago it was alcohol or heroin but today it’s everything.  

“I don’t want the methadone or suboxone. I was just told I had to see you and fail your program before they’d give me the free heroin.”  He was 18 years old. He’d started using drugs when he was 6 years old. His mother was a prostitute and his father a career criminal.  “I”m pretty sure he’s my father. I visited him in jail. The guy my mother said was him. He acted okay and said we’d get to gether when he got out. He’s in for another 20 years. Manslaughter. I didn’t go back.” 

There’s lots of solutions. All the options are available here for treatment. The management of these options has been described as the worst managed in the western world.  The problem is communication and coordination.  The administration though is always playing their favourite game of divide and conquer and self aggrandizement. The emperors and empire building in beurocracy is rife.  

“I’d feel badly but when I see how incompetent the legal system is following known terrorists and dealing with criminals who use guns what is done in health care is genius by comparison.  Politics is just messy everywhere.” She said. A wise nurse teacher now working on the frontlines after leaving a cushy university position for reality.  

The housing crisis doesn’t help.  The bed bug stories and rats in 21st Century Canada frighten me.  Typhus outbreaks in Democrat California. Won’t be long before that spreads up there.  We still get syphilis cases and we’ve done everything to wipe out these diseases but as the government devolves the danger increases. We’ve got TB again but so far no Plague in Canada. The breeding grounds are growing though.  The anti vaccers don’t help either but who wouldn’t believe conspiracy theories with the lies coming out of Ottawa and Brussels about scientific ‘predictions’ that are just modern day political ‘prophecies’ .  

If the person has a job and family in tact as Dr. Ray Baker literally preaches, “We can get 80% or better outcomes at 5 year follow up with early intervention.  We do better with addiction that any of the other specialities in this regard but we are no better than they are treating end stage illness’.  Dr. Baker was the one who started the first medical school addiction education program when the authorities were in complete denial and blaming the victims like the courts and judges and too many politicians still do.  

The treatment of choice has been around since the Navy Pilot program. When AA began in 1935 there was no ‘cure’ but 50 men in Akron found that abstinence and accountability groups, 12 steps and broad based ‘spiritual’ focus rather than narrow focus resulted in 5 year cures for what was an otherwise deadly disease.  Unfortunately until people understood immunity, partial immunity and genetics of disease and disease spread little more progress was made for decades .But now, thanks to AA that millions of alcoholics were surviving and then Addicts too there were test subjects and money to continue the research that has lead to a broader based approach to the disease. The Navy Pilot program was 80% successful with early identification in the workplace, referral to a psychiatrist trained and experienced with addiction , seeing them monthly, seeing a drug and alcohol counselors weekly and attending three AA meetings a week after an initial 4 to 6 week (proverbial 28 day) inpatient treatment.  

There’s little change in that winning formula today except that there’s now ‘outpatient’ ‘DAYTOX’ and “SMART” Recovery groups alternative to the 12 step programs and a variety of faith based ‘accountability groups’ more appealing to particular religious affiliation.  Psychologists and psychiatrists have begun to treat the trauma that is usually associated with addiction at 3 to 6 months abstience.  Motivation Therapy and DBT groups are now psychological advances over the CBT developed in the 80’s .  Recovery Capital work is the foundation of modern psychosocial therapies. 

In addition a variety of drugs like Revia 50 mg a day have been developed to reduce craving and assist recovery much like the highly successful Chiantix used for quitting smoking. 

Harm reduction strategies have expanded the applicability from the original , ‘take it or leave it ‘ approach so that a number of approaches have been established to get people into the now generically termed ‘RECOVERY’ process. It’s becn said ‘you’re either on the up elevator or the down elevator.” Once it was believed that you couldn’t be ‘forced’ into recovery but functional MRI studies show that people who have been using drugs are literally ‘not in their right minds’ for at least 90 days or 3 months.  Intervention and rescue models and treatment Centers offering 3 month initial programs have followed this learning. The old ‘tough love’ AA program is still likely best practice for ‘relapse prevention’. 

 These harm reduction procedures include replacement models, like methadone, suboxone, and now morphine and injectable morphine. Internationally the highly successful injectable long acting antagonist treatments have been used though Canada and the US often because of the long delays haven’t  haven’t caught up with the Russian and Australian approaches to chronic relapsing disease. . Mostly the local  courts and beurocrats cause delays because of their lack of  scientific education in face of  crisis.  When I worked with the AIDS epidemic the courts and individual judges and beuroccrats by their delaying tactics and self aggrandizement accounted for thousands of passive aggressive deaths.  That said hundreds  of judges and thousands of beurocrats along with the front line workers turned that disease around as they are now grappling with this fentanyl epidemic.

Dr. Jordan Peterson though, always one to avoid the political correct language of deceit, confronts the problem directly but saying that today 10% of the population are ill equipped to have any work. Work and the family are the cornerstone of community and without community the gangs and drugs take over.  Work has been a key component in limiting the spread of addiction.   It literally keeps people in contact with positive associations however as Dr. Peterson points out in the past there were all kinds of work that didn’t require intellect or computer knowledge or even reading and writing. But these kinds of jobs have been mostly taken over by machines. Society must come to terms with this problem. Some countries have brought back conscription while others are moving to a similar non military but public health peace corp type approach for those young people who are not going to make it to college or trade schools.  Anything is better than leaving these marginalized people to gang predators.  Some 75% of those in jail are there for crimes to obtain drugs.  The enablers are often those with a conflict of interest in maintaining the antiquated punishment jail based legal system which has much value but not in this arena.  The drug court is just one of the very best solutions to the problem but recovery houses and work must follow.  

The good news is recovery is working. A week doesn’t go by that I don’t meet someone who says they remember me , like others,  who were along the way in their recovery journey. They stop me and say ‘thank you’ .  I don’t remember them. I’ve seen so many thousands of patients struggling and recovering from the disease.  They never look like they did when I met them in their addiction or early in recovery. 6 month, a year or 10 years later the big difference to me is the ‘eyes’.  They look alive’. “Dead eyes’ is a well known term among those who care and know.  

What’s even better is the ‘life’ the people in recovery have.  They tell me about their new jobs, their education, the trips to exotic places, their reunions with family, their church or temples.  It still remains that those who are 20 years or more recovered tend to be going to AA groups or involved in some spiritual organization.  

It’s a tough field to work in especially with the alcoholism and addiction rampant in the authorities  and the denial in high places where the desire is to expand the tax base and hope that the 90% of people who can play with fire safely are not destroyed by the 10% of people who turn out to be arsonists.  Despite that it’s still rewarding in time to see the lives gained.  Those young people who I knew who had so much potential but died premature unnecessary undignified deaths still remain with me.  But the woman who lost her children and family is now 2 years clean and sober . That’s thanks to methadone, her drug and alcohol counselors, AA,  a smart psychologist, her local church, an enlightened social worker and family who were glad to have their daughter back. She has a job working as a secretary for a housing authority, a government beurocrat going out of his way to help her get work without stigmatizing her for the other non life she’d lived before recovery. That’s the new normal story in this work.  I’m thankful to have been a part of the recovery process.

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. 

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.

Drug Induced Paranoia

He had just walked into the room. Big guy.  Lots of chains and tattoos. Unwashed hair.  Poor eye contact.  Slouched down in the chair across from me.

Lifted his head.  Stared at me.  Real hard.

I waited.

"I don't want you writing anything down." he said.  Low voice, Controlled. Ordering.

"I take notes. It's what a doctor does.  It's the law." I replied, softly.

When you have worked here long enough, you've heard it all.   You feel the insaniety  though.  Maybe it's in the tone.   It feels  palpable.

"I don't want you to write anything down. I know you doctors give your records to them.  That's how they know everything. I don't want you writing anything down."

"What do you want from me, then?"  I didn't ask about them.  Them is them.  If you have to ask you probably don't know.  He walks out and you don't see him again.  So much for caring.  That kind of stupidity is 'selecting'.

"I want my drugs."

"Your methadone?"

"Yea."

"Are you doing any street drugs."

"I'm not going to answer any of your questions.  You're just going to tell them."

"Who are you worried I'm going to tell?" Now it's right to ask about them.  Things are moving along now.

"Everybody.  The only way people know I do drugs is someone tells them. I don't want you telling anyone else.  I know it's in my record but that's because doctors won't shut up and just give me the drugs I need."

I'm old. I'm afraid.  I didn't want to tip him over the edge. I was just seeing him in passing.  I've never seen him before, might not see him again.  I'm just covering for a colleague.  I peruse the chart, peripheral vision keeping track of his torso.  The chart shows  hes been doing crack and crystal meth. He'd actually been doing well.   Not using heroin like before. My colleagues a good doctor.  Maybe the guy was just pissed to see me.

I wasn't well.  Feeling fairly irritable myself.  The air was bad here.  Smoke and pollution blowing up from the forest fires in the south.  The lighting was already bad in this building.  Hazy. Eerie.  Besides a garbage truck had spilled out back.  The bad air now stank.  Couldn't get worse.

He was probably having a bad day.  Something must have happened before he came in.  He wouldn't leave a urine.

"It's going to be positive for crack".  he said.

I thought that was progress.  I didn't want to push him.   I could have followed the rules strictly, goose stepped, clicked my heals, shouted Heil Hitler.  There's real advancement in that approach. On the other hand, people who do that,  usually have 'burn out' and 'compassion fatigue".  Sometimes they're just new and afraid.   The system doesn't want anyone to know about the Jews and Auschwitz. You're supposed to crayon inside the lines.   I took an Oath "Do no harm".  Days like this I think it's a curse.      It wouldn't  help him, my being hard.  I wanted to keep an open mind.  But not so open the marbles fell out.   Only people far from the front survive being pollyanna.  They're the critics.

I gave him the medication.  He'll be back in a few days to see his own doctor.  After he left I wrote a brief note. No harm done. Gave my colleague a heads up.  Somedays, we bend a bit. Sometimes we don't.  Maybe it's was just the air. Maybe it was them.

Christmas Eve

I'm working Christmas Eve. Here in the Downtown Eastside Vancouver.  I'm seeing addicts who have chosen a different direction in life.  Leaving injection adulterated heroin and the darkside they've begun their journey of recovery taking oral prescription methadone.

"Methadone is a godsend,"  my patient just told me.  He's looking to return to work.  No longer fearing the deadly diseases associated with IV drugs, he's looking to return to work in the New Year.  "I couldn't work."  Heroin had taken over his whole life. Now he has a girlfriend whose also on methadone and they're celebrating Christmas together with turkey dinner.

So many of my patients have had the last dime of their money taken by the drug pushers.  Drug pushers are sad.  At the top of that dung heap is the guy addicted to money. At the bottom is the guy whose psychopathic devolution is such that he'll enslave his fellow man for his own comfort.  Most of my patients are just victims.  They used their welfare checks, turned tricks, gave blow jobs to bullies, did petty crime. When they'd had enough self abuse they walk through the doors of Doc Side Medical Clinic on Main Street.

There are other such places.  Clinics where methadone doctors are licensed to help this marginalized population of ill.Some start their journey going to NA and AA.  Others start here , stay on methadone maintenance like any other medication but become abstinent in all other regards, return to work and families, pay taxes, and return to law abiding citizens remembering their days of addiction as a bad nightmare.

Right now my friends are helping the homeless with coats and food.  Many of those helping once had addictions themselves. Not all homeless have addiction. Too many of the homeless here are those sad and tragic people who because of mental illness were well cared for in state mental institutions. Now those have closed and too many of the mentally ill are the prey of the drug dealing predators, those parasites on society.  Too often I see the families of the mentally ill who can't wrest their loved ones from the representatives of organized crime.  The police do all they can.

We do what we can.

(Patients come and go. It's steady.)

Christmas eve is the lowest time of the year.

In the morning we will celebrate the Birth of Christ.  Hope for a new age. The promise that another year will come and life will move forward.  In pre Christian days the winter festival celebrated the hope of the new year.

The crocuses come out in February here, at latest March.  Patients seem so low then at some nadir they rebound and come back as if from the dead.  Dark night of the soul.  The 'bottom'.

The New Year comes that way.  This year waning.  The light dwindling.  Then the return of the sun.  My generation's Beatle song "Here Comes the Sun!" celebrates the spring as none other can.

The renewal.  The new beginnings.  And a baby cried in a cradle.  A new age began.

There is hope.

Dr. Shaohua Lu - Addiction and Consultation Liason Psychiatry

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

CSAM - Canadian Society of Addiction Medicine - 25th Conference - Ottawa - October 2014

Evolving Perspectives on Addictions (Perspectives Evolutives en Dependences)” was a great success with participants from accoss Canada and the United States.  President Ronald Lim and Conference Chair Paul Sobey,
combined with many others to make this educational experience at the Marriott Hotel clinically extremely beneficial as well as addressing evolving controversies.   Having a Methadone Clinic to attend at Dr. Gary Horvath’s DTES Vancouver Doc-Side Medical Clinic on Wednesday I didn’t make the first day though heard it was extremely well received. All the research and scientific advances in the study of electronic cigarettes and marijuana smoking were addressed.  Thanks to Paul I was emailed   Dr. Mark Wares latest paper.
Dr. Alan Budney , President, Division SO American Psychological Association presented on new regulations related to Marijuana.  Dr. Peter Selby updated the group on Motivational Interviewing.
All of the slides and references for conference are available on the CSAM site.(www.csam-smca.org/Office 403-813-8217)
Dr. Jeffry Turnbull, medical director of the Inner City Health Project, Ottawa presented on evolving psychosocial approaches to Addiction treatment while Dr. Tara Tucker addressed the critical issue of Compassion Fatigue.
Dr. Kim Corace, Director, and Dr. Melanie Willows, Program Development and Research in Substance Use and Concurrent Disorders Program, Royal Ottawa Mental Health Centre, spoke on Bridging Research and clinical Practice:Key Strategies to creating innovative addiction treatment services.  Their presentation addressed the need and importance of the Hub and Spoke Partnership Model, the networking involved and how to get key players involved in the coordination of effort.  It was clear that a whole lot of work and effort had gone into the obvious successes of this remarkable program.
Mel Kahan,
Medical Director, Substance Use Service, Women’s College Hospital, spoke on the Rapid Delivery of Addiction Medicine Service to patients in Detox Centres and Hospitals: the H-SOAP project.  Dr. Kahan is truly one of my favourite ‘rock stars’ of Canada’s Addiction Medicine. His program identified that addicts with their particular series of crisis needed to be deal with  a hospital based service that was responsive to emergencies, psychiatric and internal medicine wards providing the critical cost saving and clinically relevant service at the time they’re needed not weeks or months later.  With his vision and experience he has developed a working model in his community that is practical, profitable and very timely indeed.





Dr. Corey Waller, Medical Director of Spectrum Health Medical Group Centre for Integrative Medicine presented on the major news topic of Prescription Medication Abuse. He was a very exciting speaker with humour, anecdotes and challenging considerations for advocacy at the highest levels.  





Dr. Marie-Eve Morin was a true delight presenting in French on the topic of the Doctor as Drug Pusher.  The conference had provided electronic sound devices for the real time translation of her superb talk.  My french is rudimentary so I really did appreciate this assistance and knew my American friend was loving this ‘international’ aspect of the Canadian conference.  Dr. Marie-Eve Morin’s reviewed the problems of prescription drug abuse, the history and recognition of these in Quebec and the advances in addressing the issues her and her associates had made.   It was a thorough and riveting presentation. C'est bien! Magnifique!
Dr. Beth Sproule,
Clinician Scientist, Centre for Addiction and Mental Health, presented on A Case for Pharmacists and Prescription Monitoring Programs , Decreasing the Harms from Prescription Drugs.





Dr. Melanie Strike’s presentation was very well received, a very revealing presentation of clinically relevant research and insights that really did touch the core and complexity  of concern in the front lines of therapeutics.






Dr. Nady el Guebaly, the humble leading light of  International Addiction medicine has just published the definitive textbook of addiction medicine through Sprinter.com (ordersny@springer.com) “Textbook of Addiction Treatment:International Perspectives” Nady el Guebaly, Giuseppe Carra and Marc Galanter.
Dr. Nady el Guebaly introduced Dr. Ivan Montoya, National Institute of Drug Abuse (NIDA, Director, Practice Research Network, American Psychiatric Association. Dr. Motoya did a comprehensive review of the evidence based research on pharmaceutical treatments to date and introduced new treatments ongoing and/or under review.  This was a very exciting look at the possible future of pharmacotherapy with it’s attendant hope for those still suffering.











Monica Bawar, PhD Student,  Neuroscience program, and Brittany Dennis, PhD Student, Clinical Epidemiology and Biostatistics, McMaster University, presented an elegant study on Factors Affecting Treatment Outcome for Patients Undergoing Methadone Treatment for Opioid Addiction: A Focus on Sex Hormones and Chronic Pain. I was delighted personally to learn from this research that testosterone levels are related to dose of opiods and that there didn’t seem to be any evidence that one opioid acted differently than others. My methadone patients occasionally complain of reduced libidido when they start treatment which struck me as strange because most of the heroin addicts in general complain of lack of libido secondary to any opiate use.  Heroin has never been considered a sexual performance enhancing drug so it was helpful to hear the detailed work of these researchers who also addressed how factors of chronic pain might well contribute to relapse in methadone patients.








Dr. Andrew Smith, Staff Physician, Pain and Addiction Medicine, CAMH presented on Partial Agonists and Half Truths: The Use of Suboxone in the Treatment of Chronic Pain. Dr. Smith’s presentation was a most interesting case presentation with remarkable insights and developments that spoke well to the true complexity that clinical practice presents.  It was really helpful clinically to see how an otherwise difficult and tragic case of a highly successful individual with chronic pain could be best  addressed. The use of Buprenorphine was critical in the resolution of the case which had a previously hard working man utterly prostate with disability but with appropriate care back at work and doing the recreational activities that they so enjoyed. It really did speak to the miracles that we all have seen in this difficult but rewarding work.


“What’s New in Hep C” talk by Dr. Curtis Cooper, Director, Ottawa Hospital Viral Hepatitis Program, was a fascinating  simply for telling us about the facts and success of the new and highly effective treatments for Hep C that are now available. The difficulty that remains is getting the funding for these truly historic advances. 








On this positive note with a celebration of all the new research and advances in the exciting cutting edge field of addiction medicine, the conference closed. Next year’s conference will be in Calgary Nov. 5-7 at the Coast Plaza Hotel (admin@csam-smca.org)
Personally I was delighted to buy Dr. Merville Vincent’s book, Diagnosing and Treating Addictions, An Integrated Approach to Substance Use Disorders and Concurrent Disorders.  Ms McCullough, now in Toronto with Edgewood,  formerly of Vancouver was in the welcoming room when I arrived. It was great to see her again.  Dr. Vincent, psychiatrist with Edgewood is one of the best clinicians in the field but also a very clear thinker in what can often be a fuzzy area. His lectures have always been well worth the effort to attend.
I was equally delighted to actually see Dr. Nady el Guebaly’s Textbook of Addiction Treatment:International Perspectives.  Copies were present for perusal but we couldn’t buy them on sight but had to order from the publisher.  Seeing them was worth the wait as all of us in Addiction Medicine have been looking forward to this comprehensive text. This book had been the talk of the Kuala Lumpur Addiction Medicine conference I'd attended last fall. Now I’m waiting for my copy to arrive and many hours of enjoyable reading this winter.
 For the flight home I was thankful to obtain the latest Canadian Journal of Addiction, the Special Edition: Medical Marihuana: Furthering an Objective Debate. Given all the nonsense in the media and the lies perpetrated by those with  major conflict of interest I’m looking forward to reviewing the truth and science of the matter.   The journal has  articles  by Dr. Nady el Guebaly, Harold Kalant, Mark Ware, Meldon Kahan, Shery Spithoff and Anna Reid.  What a great read this will be.
Thank you CSAM organizers and presenters. What a great conference! A bientot!