Gratitude, Resentment, Grief and Aging

I am thankful for my fingers, Lord.  The knife cut I did to my index finger did not severe a nerve.  The joint capsule may have been penetrated but there is no more infection.  Daily iodine  with hydrogen peroxides and bandaid changes has saved the finger.  How come I was not so careful initially when I was washing the knives.  But thank you Lord if there was any lesson I was to learn from my injured  ‘pointing finger’.  I have not had to at least have it removed. I’m grateful for that.  Help me always to see more my own faults than the faults of others, or the faults of the world.
Thank you Lord for the health of my dog.  I was so devastated when he was paralyzed that day. I was in fear all day as we drove back early from the north. Thank you for X-rays and Oak Animal Hospital and the lovely Indo Canadian veterinarian who did a thorough examination of him and found his nerves had not been injured, that he would walk again with medication. Thank you for his slow recovery. Thank you for science and medication.
Thank you for the end of elections. Help me to recover from all the hatred and shame I experienced again for standing up for what I believe in.  For years I have taught people ‘love the person’, don’t accept the behaviour.  I have taught that guilt was what we felt when we did something wrong but shame was what we felt when we felt we were wrong fundamentally as a person.  I have experienced so much shaming.  Throughout the election and even now I am told by so many that I am not a Canadian because I do not believe as the victors do.   Always shaming. Always ‘ad hominem’. I have never been ‘good enough’.  I have always been ridiculed and condemned.  Meanwhile I serve like an untouchable, treating unclean bodies and unclean minds.  Men and women get rich off the sales of alcohol, tobacco, marijuana, heroin, cocaine, poor lifestyle, unsafe practices, yet I am there serving, healing and helping and I am told I am not worthy to live here.  I am unwanted.
I treat many old men like me.  Some old ladies too.  There is sadness in aging. There is sadness in a whole variety of poverties yet some poverty takes precedence.  The single mothers go to the front of the line while us men whose children were aborted are shunned.  We stand in lonely groups sometimes touched by the men and women whose children were killed in crime.  I huddle next to them.  Their sons and daughters murdered or killed in war or by accident Somehow we face dying together in the greatest of loneliness. I have no tie to this world, no illusion of immortality.
And so much I gave in taxes, taken from me, voluntarily though, I had no choice, to pay for education and children and I supported the children of others knowing my own were killed.  I am a laughing stock.  Worse than a cuckold.  The women jeer at us men whose lovers killed our being and say ‘you deserved it’. Man. I’d rather be a hammer than a nail.
I am shamed for being a man. And I’m not even a very good one.  The heterosexuals hate me because I’ve had sex with a man and the homosexuals hate me because I’ve had sex with a woman. I’m divorced and divorced men are the scourge of the earth.  Divorced women were obviously done wrong by men but divorced men get what they deserve.  They’re contemptible.  I was punished and condemned in the courts, laughed at by the judge whose eyes did not look at me but instead focused on the loosely covered breasts of the one who had once said she loved me.  As I once said I loved her.  In the end I paid her all I had financially. She was smug in profit.  The courts made their money too. The judge looked like he wanted to have a tryst with her.  He ogled her. She looked coy.   I was thrust aside. Loser. Fool.  Shame and humiliation.
50 shades of grey.  The billionaires are worshiped.  The women read with lust what girls are willing to do for the monetary winner. Eva Braun ruled all of Germany.  Only her man is condemned.


My mother is dead.  She didn’t do drugs or drink.  She insisted we go to school. She loved education.  She insisted we go to Sunday school and church. She loved the Lord.  She insisted we play hockey. She and my father loved hockey.  So I fished with Dad and hunted and fixed cars with my brother and my father. I learned cooking from mom and mixing cement from Dad and I helped him build buildings and boats.  My parents had lost so many friends in WWII.  Dad had served in the RCAF. A spitfire mechanic and a bombardier.  My parents met in the war.  Dad and Mom weren’t racists. I didn’t know racists till the government began dividing and conquering the people by calling everyone racists.  My black doctor didn’t even know he was black in those days like I didn’t know I was white.
Dad didn’t know that being a man and being white was wrong.  He didn’t think of himself as coloured.  My mother and her sister had black friends.  They were Baptist.  She didn’t have Catholic friends.  Dad had Catholic friends and Jewish friends and Buddhist friends and Hindu friends and secular friends.  Our family were as coloured as everyone. Mom joked about us having freckles.  My brother and her had red hair.  
Dad liked smart people, people who did things, ‘made something of themselves’.  Always growing up I heard my parents say, “It doesn’t matter where a person has been it’s where they’re going and are they building things up.”  Mom and dad most admired people who were working and taking care of their children.  They didn’t like people who were ‘living off of the government because they were too good to do a honest day’s labour’.  They didn’t like people who weren’t willing to ‘get their hands dirty’.  They especially didn’t like people who stole and criminals.
 “I didn’t fight for this country so I had to put a lock on my own doors,” my father told me.  The judge who lived a couple of houses over was a rip roaring falling down drunk and my parents didn’t have any time for drunks. They especially didn’t like drugs.  “Wasting their lives.  Caring for their own pleasures when they should be caring for others.  Not caring how much their behaviour hurt others. That’s their problem."
They both said, “You always were too smart for your britches.”  “I don’t care if the teacher is wrong, you’ve got to learn to not tell them that because they’re hurt you for it. The more wrong they are the more they hurt people who are right.” My aunt was Indian. My Baptist aunt was the executive assistant (we called her his ’secretary’ back then) to Canada’s ambassador in Washington DC during WWII. My grandfather arrived as a poor immigrant from Scotland and homesteaded northern Canada to become a great rancher and lumber man.  My other grandfather arrived from Ireland. Both poor, the “made something of themselves.’  They “didn’t take handouts’.
My aunts and mother told me the history of things.  The teachers told me lies. I was strapped by the principal for correcting them. The same occurred in chemistry when the teacher had the equations wrong.  But he didn’t have me strapped. He corrected his equation and thanked me.  That’s probably why I liked science.   We were caned in gym class, our buttocks bared.  I got my first ruler in kindergarten.  The female teacher undressed me in front of the class and held me across her knees smacking me hard over and over again on my naked bottom.
Much later I was punished for stopping men and women killing people. The people whose job it was to ensure the safety of the children hated and shamed me for stopping the killing. The provincial enquiry years later vindicated me but a half dozen babies more were killed before that occurred.  I never received an apology. I was never returned the money and time I lost for doing the right thing. I was suspect then. I didn’t keep quiet and mind my own business when I saw people being killed and raped.  I wasn’t a ‘team player’ they said in the government.  There is no “truth and reconciliation” for ‘whistleblowers’.
I’m surprised I don’t like S and M.  So many boys have come out of school spanked so many times like me that they at least got some pleasure sexually later from their twisted education.  I just got this twisted idea I’d stop people being abused. I try mostly to stop people from ‘turning anger inward’.  They continue to hurt themselves after being hurt so much by others.
Now the government tells me I can’t touch people.  Standing helpless in my office men and women cling to me and their tears run down my suit.  I cannot hug them.  All over the province men and women physicians are being publicly threatened fines and loss of license if they touch a patient, especially if they hug a patient.   I eventually push them away and tell them the government says that doctors can’t touch their patients even when they are grieving. There are so many laws today.  I am afraid of everyone and everything.

Thank you Lord for these moments of peace. Thank you Lord for bringing me safety this far. Thank you for the light. Thank you for the coffee and the cream and the porridge. Thank you for this computer. Thank you for letters and language. Thank you for the opportunity to learn. Thank you for the chances I’ve been given to make something of myself.  I am still walking upright. I’m still able to help others.  I am so thankful that my finger still works. I am always in pain, Lord.  I am just so thankful that it’s not as bad as it has been. I am so thankful that I can get out of bed and get to work and have some work.  I look back and remember the abject poverty of those years of being a student, giving blood for books, not having food because I paid the rent, eating at family and friends because I had no money. We were in love then. We lived so simply.  Years and years of hand me down clothing, hand me down furniture.  We pooled our resources for a party. I studied from 6 am to 12 pm and saw formulas in my sleep.  I lived in hospitals.  I went for years without sleep.  Plane crash. Polar bear chasing me.  Deadly diseases.  Old people dying in my arms alone in the night giving me their last words as gifts.  I thought I’d never get clean. The lice, the bacteria, the virus, the sickness. I was sick for so many many years.  Tuberculosis. I was treated for a year.  She condemned me for going where no one else would go. “You’re not a Christian, you’re a fool.” she told me when I wanted her nakedness and she was angry that I flew away to serve the aboriginals because, “no one else would’.  Now no one cares.  The government regulator sneered at me and said, “It’s just a job.”  I’ve never got my back pay. There never was a bonus.  Everyone said I had status but ever shopkeeper raised the price and stole from me.  All the while the government took in taxes and paid themselves fat salaries and froze my income.  Among ourselves we laugh if we make minimum wage.  7 days a week for how many years is it I worked and was on call. No overtime. No on call. No danger pay.  I fell asleep in an operation.  I wet myself too.  An adult man peeing dribbling unable to hold it. all night with an unforgettable bowel after a shot gun wound.  I wake with nightmares screaming lost in guts that are perforated seeing faces of suicides. It’s a good week when I don’t remember, when I get a full nights sleep.  This morning I woke at 5 am.  Now I know it’s just the rain.  It’s the darkness and the rain. It’s that season. I remember the rains coming and the palm trees flying over my car, my windows knocked out.  The rains and the darkness. I’ll get used to it again.

Thank you Lord for the memories. When I smoked pot and drank wine I forgot.  I don’t remember my holidays. Those brief weeks when we’d get away from the ‘front’ and escape to beaches.  I drank wine and smoked weed and now don’t much remember those days while the horrors of guns in offices and knives and the angry faces fresh from jail in withdrawal demanding valium and more valium or narcotics and more narcotics threatening shouting.
She said I ’sexually harassed her’ when I asked her to leave because she was stealing and smoking crack. She ‘d been raging and shouting at the Indo canadians in wheelchairs.  She hated Indo Canadians.  I didn’t know when I hired her. I didn’t even know she was a drug addict. I didn’t know she prostituted. I took others words. She lied. I didn’t know her johns had been her references. I didn’t know that her minister was her bisexual lover. I’ve never known anything when the shit hits the fan. I’ve been so focussed on saving a life that I didn’t know that I was being stolen from. Only when the bank balance didn’t match did I know something was wrong.  Only when I saw the receipts from the store did I realize that she was a thief.    Everything she said and wrote didn’t match. Lawyers showed that.  A hundred lies but it was never about truth.  I told the truth and was condemned for it.  Government’s don’t want the truth.
The government woman said, “Women don’t lie about sex.”
I learned there was no ‘justice’ and went to work pro bono with my friend who was killed when he said that only the rich could afford justice in Canada.  I still think it was a hit.
Thank you Lord for the lifting me up. These moments come and go. The set backs. Reflecting on people saying I’m not a Canadian.  People telling me to leave Canada and that I’m not wanted here.  It took me back to the time when I was getting death threats, when my windows were shot out by 22’s, when my cars was keyed over and over.  I had been diagnosing alcoholism and addiction and saying that people were unfit for work. The management thanked me for halving the accidents on the job. Men and women thanked me for making their workplaces safe but the cost was high. Drug addiction changes a person.  The pot heads were just as violent as the alcoholics and cokeheads when it came to wanting revenge.  Here there were having this good thing, the doctor before me saying they were depressed and giving them a week or two in hospital to dry out before they went back to work to wreck havoc on management and their fellow workers.  He was the loved doctor.
"The other psychiatrist  never asked about alcohol and drugs but this knew little shit doctor did and he fucked me up. The fuck cost me my job writing down what I told him I smoked and drank. It was supposed to be confidential. When the insurance company saw it they said that I had to go to treatment. I didn’t want to quit.  I just wanted the other psychiatrist to keep writing a note saying I was sick because of my bipolar disorder.  I didn’t want this fucking asshole to fuck me up.  I talked to everyone about him.  I didn’t think it was relevant to tell anyone how much weed I was smoking when I was working.  It’s medicine. It’s a herb.  It’s not like the pharmaceutical’s that little shit puts people on.  The boss is just like him. A fuckking shit. Keeps telling me I’m forgetting and not concentrating on the work.  Claimed I caused their multi million dollar machine to break down.  All the stress he was giving me made me do coke. I needed it to concentrate at work after I started the day with a few shots and a doozie or two.  Then I go to the hospital for my normal break, like we all did with the old doctor and this shit blows the whistle.  Of course I hate him.  Fucking boy scout.  Little do goober.  Of course my friends and I made his life miserable. After what he did to us he’s lucky he didn’t have an accident."

Now I’m just sad, now , alone.  Thinking how many lives I must have ruined drug testing.  If I’d just backed off, turned a blind eye like my colleague, these guys might have gone on to be Prime Minister or at very least headed the company. Instead they probably left regular work and went into growing dope full time and becoming part of the multi billion dollar BC industry that now has essentially been pardoned as well as getting to take the money and run.
I’ve never been “pardoned" in my work.  I’m just scrutinized, regulated, criticized,  shamed and threatened. They call the punishment different names like ‘re-education.’  It’s still punishment.  The hitters get paid and the victims get framed.  When I was doing so much pro bono work, about 20% of that years income, because the parents didn’t pay their premium they and their  kids couldn’t see private doctor and they were told to go to government clinics where they didn’t want to go because everyone their judged them and put them down, I saw them.  I didn’t get paid.  May e $20,000 loss of income a year. I thought like any business I should be able to declare it as a loss so I did.  Revenue Canada sent out three people to audit me. It wasn’t an audit. It was harassment. They went through all my books.  At the end of a week, this thug said, “No doctor sees patients for free. We haven’t caught you yet, but we’re watching you and we will.”  Every private doctor I know works for free but we’re not allowed to declare our ‘losses’.  Even today people miss appointments and I  don’t pay but I can’t declare my losses against my earnings like all other businesses can.  The reason is that psychopaths think others think like they do.  Lizards think other think like lizards.  So our government doesn’t do anything for free.  And they can’t understand a physician any more than an insect can understand a bird.
It’s not good to stew. It’s better to help someone. I am so thankful. When my mind wasn’t working I used my body to carry folk. When I couldn’t lead I followed. Today I know the people I’ll see are hurting more.  I have so many people with cancer and surgeries and all I do is provide relief.  The heroin addicts are far gone but here and there one awakes and wants to live.  I’m happy to provide solace. I love to see people cured. But now we’re all getting older and the only cure for life is death.
I think of that too much these days.  Kierkegaard, “Life is suffering unto death’. I think a lot about my buddhist days.  I’m praying and meditating.  I miss rejoicing.  I miss dancing.  I have to have a shower and get to work. Everyone is always angry that I’m late. Some days I’m afraid to leave my office. A day of my life has not gone by that someone hasn’t been angry with me. A year in my life has not gone by that some official hasn’t hated me and tried with all their power to destroy me.
 For so many years the friends of the man I stopped killing people haunted my life. They were in so many high places and their loyalty to their drunken dangerous friend was admirable.  They were more afraid than me.  I saw that but now a couple of them have died and the others are retired.  They’re rich and have young wives and their children visit them.  They tell war stories like we all do.  They’re victors.
I don’t think I ever wanted to be a victor. Maybe if I’d set my eyes higher. As long as I can remember I've just wanted to survive and help others survive.  .  Thank you God for letting me survive. Thank you for the easing up of my back pain and the healing of my finger and my dog. Thank you that I can type.  Please banish my anger, my self pity, my negativity, my comparison, my jealousy and envy and my resentments. Help me rid myself of these character flaws so I can better celebrate this new day and be grateful for all that you have given me.

Confidentiality

Sometimes, as a physician first, and a psychiatrist, now, I see some one, a friend of a friend, a family member of a friend, the patient of a colleague, and the person doesn’t return or I hear they were upset about me.
I worry and wish I could have ‘acted’ differently, ‘been better’, ‘reassessed the situation’, shown "more sensitivity’.  Other times I think why did I disrupt my schedule, work late, miss lunch, allow someone to jump the queue only to be treated like this by an ‘ingrate’.  It fluctuates depending on mood and hours of lost sleep, missed lunches.
I’m older now and still ‘worry’ as much, but accept more.
What I notice though is that there’s something ‘missing’.  More often the person who was ‘depressed’ and ‘suicidal’ and really in ‘need’ was doing something specifically they were not telling their family, friends or doctor about.  Then I realize that they were upset with me most likely ,probably, because I was doing my job and doing my job very well.
I have patients come in with a ‘rehearsed’ ’spiel’.  This ‘story’ that they tell others doesn’t ‘ring’ true to me so I ask specific questions, like doctors do, and this ‘derails’ this sort of patients ‘routine’. They’ve got their ‘poor me’ down pat and want me and everyone else to ‘see’ things their way. They don’t want to ‘learn’ what I’ve got to say or ‘hear my opinion’. They principally want me to rubber stamp their bullshit.
But their friends and family don’t know a critical detail.
One of the most common is ‘drugs or alcohol.’  One man remains furious at me a decade later. I know his friend who referred him to me. The man drinks 80 oz of vodka a day and called me a quack when I told him that alcohol was a chemical depressant.  “I am sure I could treat your depression but you’d have to stop drinking’.  "You're nothing but a quack, I don't have a drinking problem".
A man saw me recently and he was smoking pot all day long and everyone was concerned he wasn’t motivated.  No one had a clue as to just how much pot he was smoking and how much money this was costing.
My gambler wasn’t telling anyone about his losses.  If I owed those people what he owed I’d be depressed too.
There’s no ‘magic’ pill in medicine. If you are cutting your wrists and bleeding a good doctor is going to tell you to stop cutting your wrists, take away the knife, and bandage your wrist.
But today you can get a lawyer to sue me for telling you to stop cutting your wrists claiming I didn’t ‘respect your rights’. Further a human rights commission will insist that my first obligation was to refer you to a doctor who does euthanasia.  Already the millionaire abortionists insist we pimp for them so it’s only days before the euthanasia folk will have their own financial future legislated such that suicidals are given their  ‘choice’.  No one considers the conflict of interest that a State Health Insurance creates.  
Further, you can complain to the College of Physicians and Surgeons that I wouldn’t cut your wrists for you. The poor College of Physicians and Surgeons will be obliged to berate the doctor who took an oath to do no harm.
The other thing people don’t tell people about is their illicit sexual lives. Even as a gp I was seen usually only once for treatment of gonorrhoea or certain types of bugs or warts best not discussed in ‘polite’ society.  After I’d successfully treated a person they would go to another doctor so their ‘file’ was not ‘tainted’ by their nights of forgetting their marriage.  Increasingly the insurance companies and courts are destroying medical 'records' and increasing the costs of health care exponentially because patients will go to extremes including multiple doctoring to conceal their 'dirty secrets'.
The common theme is that when people   say the ‘doctor wasn’t that good’ or ‘they didn’t like the doctor’ it may not be so 'simple'.   No one tells their mother or father, husband or wife, I didn’t like the doctor because he told me stop doing crack cocaine.  They don’t even tell their family physicians often.
A week doesn’t go by that a family physician doesn’t learn something critical about their patient after they’ve been sent to a good psychiatrist, when I say good I mean thorough conscientious or maybe just plain 'curious' about their patients.   Hundreds of times I’ve been told by collieaques, “I never knew”.
Yes, I can learn to be more ‘diplomatic’. I can learn to ‘speak more softly’. I can learn to go quicker or slower or be less intrusive or wait longer.  Yet, I’m paid for by my time and addicts especially want to do their whole ‘routine’ on you. There are people these days who want to talk to the doctor for years before telling them what the real problem is.  They want to ‘work’ you like they have ‘worked’ their family and friends. They want to do their ‘sales pitch’ on a professional.  What they don't want me to do is weigh them if they're obese, ask for a release of their records from the hospital if they're a hustler, or ask them 'has anyone questioned your drinking or drugging' rather than asking them 'how much' so they can lie by saying 'only two drinks' .
The sociopaths are even better. The fact that most people don’t know that their friend or a family member is a sociopath isn’t surprising. They chameleon. These are most often the girlfriend or boyfriend who comes along on a visit. The ‘loved’ one thinks the person is there for ‘support’ and doesn’t know that they’re a ‘hostage’ and that the ‘loved’ one wants to be there to ‘control’ them more.
There is innocence.
There is purity.
There is truth.
 There is ‘good intentions’  But where there is disease there are commonly ‘secrets’.  We are as ‘sick as our secrets’.  I learned that harsh one in physical medicine when people would come in late in the course of disease of cancer and ‘share’ ‘too late’ that they’ve had this ‘lump’ in a breast or a gonad or a pelvis or an anus and it’s hurting too much. When I’d examine the lump I’d know it had been growing for months sometimes years but the person, ashamed, usually didn’t want to tell anyone. Often it was too late.  
There is so much people don’t tell their family, friends, and colleagues. They tell their doctor and often their way of returning to the safety of silence and to the illusion of lies is to simply say “I didn’t like the doctor’.  Then they go looking for another one hoping for better 'news'.
When patients tell me they didn’t “like" a doctor 90% of the time I learn by careful concerned questioning what exactly the doctor ‘said’ or ‘did’ that disturbed the person. This is true even when it’s said about a doctor I personally think is an ass.   10 % of the time the complaint is true. The doctor was an idiot but mostly it’s because they focussed the patient on something they didn’t want to address.
The search for second opinions is commonly a search by a person for a doctor who will support them cutting their wrists while accepting the duty to bandage.  Life was a lot easier and lucrative for doctor swhen they didn’t practice ‘prevention’ and we knew less about the fact that most diseases, especially any of the chronic ones, are ‘lifestyle diseases’.
Working now in addiction I most commonly face someone who wants to convince me that anything from heroin to marijuana to obsession with pornography isn’t the problem. Mostly sons want to tell me their mother is the problem, husbands that their wives are the problems and everyone that its ‘stress’ from the boss or work.  Just ‘stress, Right?  Everyone wants the problem out there, not in here.
It’s so hard to be an artist, a physician, a school teacher. “I just need a pill, doctor.”  " I really need medical marijuania to take the edge off the crack hangover.”
A lot of people don’t want to hear the truth.  As a physician I’ve enraged, thoroughly enraged, elephant women in my practice, by stating frankly ‘you’re obese’.  Mostly though these days it's the marijuana addicts who want their 4 joints a day but also want happiness and motivation to get a job. So many of the single children in their 30's and 40's who see me don't want to leave the tit and are angry that the parent won't pay for their increasing expenses.
People want to have ’symptom relief’ and yet if we ignore the ‘disease’ and just treat the symptoms we’re not good doctors. The smokers want ‘ventolin’ inhalers to breath better, the alcoholics want valium for hang overs and percocets for headaches.  The list is endless.
I am such an amazing clinician that I could be the physician to the emperor and live making the emperors life of debauchery comfortable but the insurance companies would be furious with me and the College of Physicians and Surgeons might yank my licence. Like Michael Jackon’s doctor I could get sued or lose my license. The most demanding and critical of my patients never have the millions it would take for me to do ‘celebrity’ practice medicine for them alone. Increasingly everyone is angry with me because I won't order an MRI and a complete 'battery of tests' for any truly minor concern.  Hypochondriasis is truly common and thanks to Dr. House everyone cold is now a rare disease that stupid doctors are missing. None of my patients do statistics.  But who am I to judge, the moment I get a fever, I'm calling the morgue. The only difference is I don't want to have 'unnecessary' tests done because I know that 'unnecessary' tests almost invariably lead to more 'unnecessary tests' and even more 'unnecessary procedures'.
I loved the doctor who told me that rubbing my eyes after picking my nose was causing my recurrent conjunctivitis.  I was a university student studying all night and had several episodes of conjunctivitis. I’d seen several doctors before that. Personally I lost respect for them when the real Dr. House in my personal life truly solved my real problem.  There was no more return business. I’ve not had conjunctivitis since.  I still pick my nose but I don’t rub my eyes after I do.
Now I go to work and do the best I can and tell people what my teachers taught me and say the truth as nicely as I can knowing nothing angers and upsets people more than the truth.
I didn’t like talking about my nose picking with that doctor who had the smarts to ask.  I certainly didn’t tell anyone I had red eyes from nose picking. For maximal sympathy I told everyone it was because I was studying all night.  Some things you only share with your doctor.

What the Future Holds for Addiction Medicine in Canada

What the future holds for addiction medicine in Canada

Sept. 28 ,2013

Meldon Kahan, MD

University of Toronto

Lecture given at the Canadian Society of Addiction Medicine annual meeting, Vancouver, BC 2013. These are my rough notes which I hope will be of some benefit indicating the depth and breadth of material. Excellent presentation by a very experienced clinician and superb communicator.  Cutting edge genius!

Why should physicians treat addiction?

• broader addiction community - sees role of physicians as limitted for detox and medications

Why should physicians treat addicton

-Most addicted patients can’t attend formal treatment programs

-Patients often prefer to see their physicians

• addiction programs often have long waiting lists, complex intake procedures
• addiction programs don’t have the capacity to meet demand
• MD’s have long term relationship with their paitent - quality of provider-patient relationship more important than actual techniques use - greater predictor of success
• addiction is chronic relapsing illness
• physicians can be involved in all phases, screening, treatment, relapse prevention
• controlled trials have demonstrated that physician counselling is effective for addiction

Addiction counselling is not difficult for physicians and is similar for counsellingfor other chronic illness

-focus on immediate concrete behavioural change

genetic and physiological factors play a central role in precipitating and maintaining addiction, euphoric effects of drugs, tolerance, withdrawal

-medications for alcohol and opioid have been show to improving drinking and subtance use outcomes, decrease health care utilization, improve mobidity

-health care system has greater contact with addicted patient than the ‘addiction system’

addiction system can’t handle the large numbers

Treatment of Acute Withdrawal

-sympton triggered benzo for rx for alcohol withdrawa

-buprenorphine for opioid withdrawal

protocols prevent unnecessary hospital admission

Pharmacotherapy

-naltrexone, acaprosate, disulfiram, gabapentin, topramate, baclofen

have benefits in drinking

Opioid and other addictions

-great crisis of age is opiate addiction - primary role- reducing risk talking to colleagues about better patient selection and reducing risk of od

Where should Physicians treat Addictions

• many work in methadone clinics and addiction treatment programs
• we’re not reaching those other patients
• medical or psychiatric illness
• unstable living conditions

These patients are frequent attenders in ER and community care, and acute care

-don’t receive addiction care in these settings - remain at risk for addiction related harm

need and offten want tx 

• on site
• integrated

We need to practice where patients are

near hospitals

near teaching centres

provide consultations and follow up for emergency departmnts, hospitals, community clinics

Addiction Physicians as Teachers

Addiction is orphan medical discipline

their teacherss and mentors never role modelled addiction treatment - Sentinel Student Study

-they don’t know how

-never been taught clinical protocols

-when they see an addiction patient

--it’s not my responsibility

--I can’t help them, beyond treating complicatons

addiction MDs need to role modell, supervise practice, didactic treating

What physicians learn in med school/residency determinest their practice patterns

Addiction MDs as advocates and policy makers

-addiction treatment programs

-general hospitals and clinics

-public health

Many abstinence based treatment programs do not offer evidence based treatments

• initiation of opioid agonist treatment

• Case Study - patient was told by inpatient addiction physician that their abstinence based program doesn’t not have a philosophy of accepting buprenorphine patient  - no other medial specialty would accept their treatment being ‘forbidden’

Addiction policy in hospital

-many hospitals don’t have policy

case study of woman want ing to withdraw - given 5 mg diazepam - no evidence of CIWA use - prolonged qt -

Coroner inquest recommended that hospitals use symptom triggered benzodiazepine protocol

-large hospital has only one addiction physician

We have alot to offer

-addiction protocols are rapid, effective and simple

eg

St. Joseph Health Centre - addiction medicine service - implemented hospital wide protocols for 

alcohol withdrawal

opiate management

-elective and selective students 

6 and 12 month clinical fellowship program

initial skepticism but now fully supported

Addiction Physicians and Public Health

The Opioid Crisis

-huge increase in opioid prescribing, in response to a massive marketting campaign

-led to dramatic increase in rates of addiction, overdose death and harms

-most serious medically -caused public health crisis of generation

Pharmaceutical company and his physician lobbyist promoted idea

• opioid addiction rare in pain patients but truth is that it is common, serious and preventable
• prescribing high dose to high risk patients puts them at risk for addiction and overdose
• tapering opioids improves pain, and function and mood

compared to pain physicians , addiction physicians were very quiet

-call to action began with media, public, researchers, then later provincial governments and medical regulatory bodies

Addiction physician response

opioid guidelines

limits on high dose formulations

 defundint oxycontin

Coming Crisis

2014 Health Canada new regulations allow MDS to prescribe dried cannibis

this will harm patients and physicians

no evidence of benefit vs oral cannabinoids

Smoked cannabis not good

Addiction physician as advocate for marginalized patients

Sioux Lookout - 50,000 - prevalence of opioid addiction 50 to 80%

-suicide, overdose, crime, family break up

-attempts to introduce methadone failed

-few family physicians began prescribing buprenorphine

• addiction physicians beng to fly in to prscribe buprenorphine as locums
• provide telemedicine
• provide clinical support through phone and email
• advocate with NIHB, MOH, medical colleges re funding, licensing requirements, protocols

Over 400 people on buprenorphine

support of band leaders and comunity

local treatment programs have developed eg ceremonial, group induction onto buprenorphine

adapted protocols to rural community

aboriginal communities do not have access to safe inexpense and life saving treatments

-in most provinces only methadone mds can prescribe buprenorphine

-this would not be accepted for any other medical conditon

addiction physicains need to advocate with ministry, public, medical colleagues, funding and resources for addiction treatment,do front line work with underservice populations

• we need to model ourselves on HIV doctors of 80s and 90s

Challenges for addiction medicine

-isolation and small numbers

some addiction doctors work alone

-powerless against the harmful policies of the institutions where they work

lack of standards in addction

-others specialties have consensus on how problems are managed and expect members to comply

-culture of passivity

-other groups fill the void

Younger physicians

-evidence based

-fierce, fearless and relentless

assumer responsibility

-patients

-health care colleagues

-the public

IDAA - Orlando - 2012

International Doctors in Alcoholics Anonymous has an annual meeting each August.  It's attended by doctors, which include Physicians, Dentists, Veterinarians, Psychologists and their families and occasionally others.  Their association with Alcoholics Anonymous is not just as recovered alcoholics but also as partners of alcoholics or addicts and children of such.  IDAA is a medical conference with daily CME focussed on addiction and recovery. Since the beginning of the organization addiction has broadened as a term so pretty well anyone who has a 12 step program also can be a member.  Whether one qualifies or not is simply of matter of contacting the IDAA organization and asking.
The Continuing Medical Education is provided because it just happens that many of those attending are in the field of addiction medicine with the result that some of the greatest non alcoholics in the field have presented here in addition to those who themselves are in recovery but also are national and international authorities in addiction. Routinely there are leaders from the major treatment centres such as Betty Ford and Talbot or Homewood in Canada.   Canadians, British and Australians are also in attendance along with the very large contingent of Americans.  In additions a whole range of countries from Europe, South American, and Asia have been represented over the years.  The flags of countries from those attending are often hung at the banquet to reflect the truly international nature of the meetings.
Anonymity is a foundation of AA but while AA meetings are running throughout the conference given the range of representation at the meeting I've not seen it as a breach of confidentiality to comment on IDAA conference or membership per se.   AA asks that members don't identify themselves over the internet as unfortunately those who subsequently relapse who have become public figures in press or media can reflect badly on the organization.
Dr. David Smith who presented tonight on the Haight Ashbury Free Medical Clinic movement he was founder,  said the difficulty with the stigma associated with addiction,  and both the shame and anonymity attached to it and early recovery, is that the 'failures of addiction' and the 'tragedies' are the ones that get the widest press whereas the successes are routinely anonymous.  Dr Gallanter's work for one documents the great success of the recovery movement. Dr. David Smith spoke about the success of their addiction work as it began in the 60's.
He described his early work dating back to 1967, the Summer of Love, in San Francisco when he said that working with addicts was considered a sign of insaniety and sure fire way to destroy oneself professionally. This for me hearkened back to the teaching by Dr. Fink on 'stigma' how it affects the care givers of those diseases that are stigmatized just as surely as those suffering the  disease. Hence the  avoidance always of 'leper doctors' and the experience of those of us who treated Aids patients before there was a cure.  What started as one small  Haight Ashbury free Medical Clinic, is  today  involved in treating 4000 addicts a day in California alone. Dr. Smith said that they had  believed addiction was a disease and that addicts and alcoholics had a 'right' to medical care just like anyone else with an illness.  While today this is a 'common idea', in 1967 it was revolutionary.  The incredible advances in the understanding and care of addiction were discussed earlier in the meeting with the findings of the latest MRI and neurochemical research causing the renewal of the 1938  'allergy' hypothesis based on changes seen today in the frontal lobes of the brain.
These meetings usually draw around a thousand, IDAA itself having over the years 10's of thousands of members.  It was a full banquet hall at the Hilton and I so enjoyed talking with those at our table from all the walks of life and work after Dr. Smith's presentation.  Dr. Smith is a fellow of the American Association of Addiction Medicine.  It was attending an IDAA meeting years past that I first encountered addictionologists and decided that I wanted to be one so proceeded after already having completed family medicine and psychiatry going on to study and complete the exams for the American Society of Addiction. Following that I became a member of the Canadian Society of Addiction Medicine and the International Society of Addiction Medicine.
Coming regularly to this meeting has also meant that over the last dozen or so years and as many meetings I've come to know many other psychiatrists and physicians and their familes.  Art and Carole, Tom and Bobby, Michael, Hugh, John, Randy, Darren, Dick and Cheryl, Judy, Beth, Graeme, and so many more were here today. I feel so guilty that I often forget  names  so am very thankful for us all wearing name tags.  It's such a warm and friendly place and probably because of all the encouragement of discussion at the meeting we grow to know each other annually.
After CME there's time to chat and discuss and compare practice to what we've learned.  There's a hospitality room where we go and sit for coffee and talk about what the speakers have shared.  Another room has a collection of the recent publication in recovery. I found a book from Hazelton I'll enjoy reading this coming year.
The format of the conference is so different from other academic meetings where so often there's just 'parallel play' with the group of us attending a lecture and leaving without the depth of interaction that happens here.  Here there's this other level of critical clinical appreciation.  We actually share what we do with what the speaker has shared. Hence over the years I've learned about the practice profile of psychiatrists and addictionologists all over the world.  I've also emailed or phoned physicians I've met here at different times to get advice on personal as well as clinical problems. Many times I've had a clinical questioned especially about the politics of practice or some matter requiring experience, answered by one of the grand men or women of our field so many years my senior and sometimes a continent's distance away.
We go for dinner and coffee together too in smaller groups and that's how I've come to know about the personal lives and families of fellow attendees. There's ongoing cyberdocs and on line meetings that continue throughout the year too.
I hunt and know the other hunters.  Tonight I was eating American elk jerky one member shot in January while I was telling them about the elk roasts I'd had from the elk I shot in December.  Another couple were talking about cruising in the Alaskan waters watching grizzly bears along the shore and there I was telling about sailing the northern waters and how much I enjoyed seeing the whales in Queen Charlotte Sound.  There's some of us who ride Harleys and invariably we find each other.  I even talked with a fellow who wore a gown to raise money at a charity function while another fellow talked with me about his military service and his trauma work with Veterans.  Lots of us travel and talk about our different experiences together.  The Australian doctor is forever inviting us to come down under and I'm forever hoping to do just that while tonight a British doctor was singing the praises of crossing the pond and of course I wanted to do that too.
Each year I seem to come to this meeting depleted from work and find so much encouragment it renews my desire for practice and life itself.  There are  spiritual components  here that's are part of the program with time set aside for prayer and meditation.  Several doctors who'd become ministers as well discussed their clerical experiences as compared to their medical practice.  In some ways it reminds me of the Christian Medical doctors meetings I also attend. The CME at both is of the highest calibre oftimes better than the standard fare at secular medical meetings but the fellowship is unsurpassed.
It's only the first day and I'm already loving the meeting.
I was in Haight Ashbury in 1972 after attending the first Rainbow Gathering in the Colorado mountains.  Next years' IDAA meeting is this time August in Colorado.    The Summer of Love may have begun in 1967 but it was still going strong when I was there in 1972.    I wore flowers in my hair and danced in the streets with thousands of other young people not thinking of the traffic jams that paralyzed the city. Dr. Smith's presentation included clips of the mayor of San Francisco talking of that time.  He spoke of the difficulty dealing with the excess chaos, crime  and drug abuse that was part of that influx.  I couldn't help now, older, thinking how similiar the dark side of the  Occupy Movement was.   I'm far more partial to the music of my youth than the rapp of today and can still be heard humming Country Joe and the Fish or Mommas and Poppas tunes.     That 1972 summer I went onto Vancouver where my partner and I attended the Vancouver Latvian Song Festival with hundreds singing songs together in harmony.  They were much better behaved.  Every 5 years there's an AA convention that draws some 50,000 people into the city that hosts it.  I like that no one complains about that many sober people in their city.
Today I bought a cd of gospel music. I don't regret the past but am grateful for the fellowship and learning I have today.  I am very thankful for IDAA, the organizers and the people I'm so privileged to know.