Coroner's Report -Canadian Society of Addiction Medicine 2011

Dr. Karla Pederson of the BC Coroner's Office presented their findings on the mortality associated with drug abuse.  Dr. Karla Pederson was quick to say that the Coroner's Office was there for 'fact finding" not "fault finding".  She said , "There is no good news at the Coroner's office. We see the worst of the worst".  The following are some of the notes I took but they really don't do justice to a far reaching and very compelling presentation.

Classify death

5 categories

natural, accident, suicide, homicide, undeterminied

1)RX  Opiate Death

Cases represent person overdosing on opiate medications prescribed to them

Deaths due to opiates 2005 to 2009  - consistent - 67-80 deaths each year

61% accidental

35% sucidial

4% undetermined

gender 50/50

2)Illicit Prescription death

-start as triplicate prescription

they started as legitimate prescription but went to someone else

‘street drugs’ are excluded

pharmacy robberies happen but marjority go back to a prescription pad in doctor's office

90 to 125 deaths due to diverted medication

Primarily male problem

30 -39  principal age

seen in all regions but more in metro areas and sold on the street

Illicit and Rx Opiate deaths - may be on rise

95% are accidental deaths

problem seems more criminal

3) RX Methadone Deaths

Prescription methadone

Overdose deaths where relevant drug was methadone

Methadone precribed to individual for maintenance or for pain

It's recognised that this is harm reduction model and harm reduction patient

Carries are a common theme, but no universal

Also high starting doses, too much initital dose

60% male 40% female

40 - 59

Happening in all regions

85% accidental 9% suicidal

4) Illicit Methadone deaths

Person was not on methadone

Uniformly has to be a carry diversion

40 50 yo population peak

The take home message here was 'a carry can end up anywhere".

The presentation was extremely well conceived and brought together. Dr. Pederson was a remarkable professional and handled the most difficult questions at the end with amazing dexterity. There was concern among the physicians with the direct buying of drugs from other countries and access across borders.  The contrasting message of physicians not treating pain sufficiently or clients complaining that doctors don't give them sufficient methadone replacement medication in a timely fashion was all brought together. Especially concerning was the prescribing of excessive benzodiazepines by physicians other than the methadone doctors and the respiratory failures being ascribed as a 'methadone death'.  Indeed the discussion was one of the best following a presentation and Dr. Pederson did a marvellous job of answering the wide range of questions.  Obviously physicians as well as the coroner's office were especially concerned about death.
"First do no harm" was a concern we all shared.

Marijuana Debate - Canadian Society of Addiction Medicine 2011

Addiction Medicine Specialist, Dr. Paul Sobey refereed the marijuana debate between Canadian family physician and marijuana researcher Dr. Mark Ware and Prof. Jag Khalsa.from the National Institute of Drug Abuse.  Good humored laid back Indo American Prof Khalsa should have been the pro marijuana debater if steretypes were true. Dr. Mark Ware in comparison was such a clean cut and measured speaker by comparison. They were both extremely learned and the debate and discussion was one of the best I've heard.
Dr. Sobey did a masterful job of asking questions comparing efficacy of prescription pharmaceutical cannabinoid products, such as cesamet and nabilone,  with smoked marijuana products. Specifically Dr. Ware's research showed that smoked marijuana to date was superior in treatment of neuropathic pain associated with HIV.  Clearly there was benefit from cannabinoids for treatment of spasticity, nausea associated with chemotherapy, neuropathic pain and improving appetite in HIV patient. Other than rare examples the benefit of marijuana or cannabiniods over alternatives was negligible but physicians were generally glad to have as many alternatives as possible in their tool boxes.  . To date there had been no abuse of pharmaceutical cannabinoids noted by Dr. Ware's recent research or Dr. Khalsa's investigation.  There was a lot of 'off label' use of cannabiniods in areas where research had already excluded the benefit.  Such an example was migraines whereas there was need for more research in it's use in multiple sclerosis.
There was clear evidence agreed on by both that 'smoked marijuana' was associated with Chronic Lung Disease. Further there was overwhelming evidence that it caused psychosis and had profoundly negative mental health consequences for many.  The cost/benefit was significantly altered when the drug was now associated with causing or contributing to the development of schizophrenia in adolescents.  Further it was clearly associated with accidents, specifically motor vehicle accidents and fatalities.
Both researchers said that marijuana should not be used by adolescents.  Brain development continues rapidly to age 25 and Dr. Ware was very specific in making clear that he wanted to see more research and perhaps more use of smoked marijuana in chronically medically ill patients of older age. He was very upset that adolescents were quoting him saying it didn't appear to be associated with causing throat cancer as a justification for their using it recreationally.
Both researchers felt there was a strong need for more study of marijuana.  Prof. Khalsa was very pointed in saying that NIDA had not been against marijuana and that there were countless studies done on cannabinoids in the US. The position of NIDA was specifically against 'smoking' as there was no evidence that smoking of any kind was anything but harmful.
Dr. Ware made the telling comment that when the government introduced so called 'medical marijuana' with some 22,000 now smoking marijuana after 5 years in Canada there was no solid research component as part of this politically powered federal legislation.  Obviously any good marijuania program especially one government funded should incorporate an ongoing research component. The University of California was doing just this in the US.
With typical good humor Prof Khalsa responded to Dr. Ware's cry for more research money for the study of smoking marijuana saying that much medical research is done by private funding. There was certainly financially invested interests in the marijuana debate who had not been willing to date to back up their claims of the benefits of marijuana with research funding.  The marijuana industry certainly was making a killing but not as open to research as Dr. Ware was proposing especially in light of increasing evidence of the long term negative consequences for some and the real dangers for children, adolescents and pregnant women.
Dr. Ware's excellent scientific knowledge and reasoned  approach were a pleasant change to the usual paranoid marijuana devotee who bludgeons the medical doctor with phrases like 'organic' and 'herbal'  insisting penicillin is dangerous and marijuana is life's cure.  I
ndeed listening to both these learned men in an excellent discussion was a breath of fresh air given how smokey the discussion has been in past years.
Despite this being Vancouver, and the discussion immensely entertaining, no one lit up a joint during or after the debate.

Occupy "Occupy Vancouver"!

I confess I was impressed with Occupy Wall Street. I protested for peace in the war days getting billy clubbed at an early protest only to have the mayor wanting to walk beside me at a later one.  Over the years I've supported a variety of unsavoury radical movments from  Amnesty International, Canadian Civil Rights, Physicians for Social Responsibility. Doctors against Nuclear War, Psychiatrists against Political Abuse of Psychiatry and now Christianity.
I knew there was alot fishy in the upper echelons of world power not just by the smell but mostly by the 'cover ups'. Nothing proves a 'conspiracy theory" better than the degree of effort made to 'cover' the 'conspiracy' up.  So something wasn't clearly right about the plane crashing into the Pentagon and no one getting fired but rather key players getting promoted.  Then only one picture was released to the media and hundreds were withheld.  I love all the 'deleted' bits of transcripts which are done to protect 'security' but mostly have the names of girlfriends and drug dealers on them.
Worse was the Israeli act of piracy on the high seas, the theft of all the journalists cameras and then the release of one picture showing unarmed sailors defending themselves against machine gun weilding grenade carrying kevlarred Israeli paratroopers.  The recent Bahrain 'trial' of the doctors who simply doctored to those shot by security forces was as much a mockery as the increasing cover ups out of Syria.   Then there's the billions of dollars of aid money that went missing in Afghanistan and a whole bunch of naughty bits which make wiki leaks the greatest contribution to mass education in the history of civilization only to have the Eva Brawn sisters claim that an Australian awkward genius could actually sexually harrass a couple of Swedish bimbos.
So I didn't like Goldman Sack and the other economic royalists making a killing for themselves individually while wiping out veterans pension funds and causing a global crisis so they can get themselves some Swedish bimbos.  It seemed that businessmen who said 'trust us' had proved no better than the communists and fascists before them who said 'trust us'.  It seemed appropriate that they should have some sign carrying ruffians in their neighbourhood.  Wall Street was long to chaste for the whore it had become.
But that's not Occupy Vancouver.  I like Vancouver. I was living here paying taxes and working before the squatters turned the centre of the city into a bad campsite.  Even if Vancouver is a gangster town built on BC bud and pot smoking individuals Hollywood North and Los Vegas north,, this little Amsterdam  helps heroin go freely into the United states across our once sacrosanct borders.  It's making Asian businessman rich and supporting the motorcycle industry in our town.  The americans quite rightly are  improving their own economy by developing drones released from war duty for homeland security  watching  the border of British Columbia Washington state where millions of dollars of illict drugs traffic along with how many illegal aliens is anyone's guess.
But what has Emily Carr and the Art Gallery got to do with all this?  We have a bull on Georgia street that's in the centre of the Vancouver's 'wall street' district. So if we're going to be in sympathy with Occupy Wall Street we should at least be seeing the protestors congregating where the greatest bull shit is.  But no, instead we see these pretty boys and girls, fat cat kids, and burnt out hippies in the middle of the city, at tourist central, in the prettiest part of the city, in front of our monument to creative genius and west coast art.  Here we have a bunch of urbanites who know nothing about camping learning to be boy and girl scouts without adult supervision. The fire depeartment with more sense has pointed out the ignorance of the protestors about basic matters like 'safety' and 'city planning'.  Yet these relatively unworldly incompetents big on talk insist they know better about running the world than the likes of so many of our leaders who paid with blood and dues long before they entered the ugly world of politics.
So I'm a wilderness expert and West Coast trail hiker and back woods camper.  I 'm older and I'm tired of working and paying taxes and seeing my tax money go to hockey hooligans  and  ill behaved squatter children needing  police protection.
I recently got a parking ticket for having my F350 diesel truck parked overlong on the street at a meter. I want the City of Vancouver to give me back the money I paid. I want the City of Vancouver to return every parking ticket fine that they collected these last two months since us law abiding citizens should receive equal treatment.  Fair is fair.
Further after decades of wilderness camping I got an RV last year. I'm thinking that if the city has opened a campground in downtown Vancouver for silly tenters then RV owners like myself should be able to move our RV's into the centre of the city if only so we can save money on the fuel costs of our daily commutes.  I'd like to drive my diesel truck pulling my RV onto the front lawn of Art Gallery and perhaps squat it on some squatter tents.  What day would be good for all RV owners to congregate in the centre of VAncouver for maybe a week or a month just to get the attention of the city officials who don't seem to be doing their jobs anymore.
All I'm hearing is that these people who apparently don't have to work, or pay taxes and are above the law, possibly living on welfare, parents trust funds or whatever kind of special deals they make by extortion and threat of violence are professional protestors and paid activists with an agenda of self aggrandisement and a need to be on facebook.
It was once relevant but that's getting old quickly and detracting greatly from what was initially an interesting response to the corruption in high places. The corruption in low places is now just mirroring and offering nothing new. The Occupy Vancouver squatters are just the pink collar equivalent of the white collar Goldman Sacs bullies.   I don't hear anyone caring for the blue collar workers like myself who continue to work and pay taxes while everyone else seems to be having a pity party at our expense.

Old Chevies with campers line up on Robson. Fifth wheelers on Georgia.  Towables line up on Burrard. RV's ho!

Canadian Society of Addiction Medicine, Vancouver, 2011

The Canadian Society of Addiction Medicine annual conference opened today at the Hyatt Regency in downtown Vancouver. Today I was especially lucky to catch Dr. Nady el Guebaly first thing in the morning. He's been head of psychiatry in Alberta and head of Canadian Society of Addiction Medicine and the International Society of Addiciton Medicine. His scientific research is impeccable while his clinical insights are truly revealing. Having presented an concise the whole overview of the field he spoke briefly on Gallanter's research on spirituality and addiction treatment, saying "I tell my patient's they're lucky if they have belief."
I was sorry I'd missed Dr. Paul Sobey's presentation. We met some decade or so back studying for our American Society of Addiction Medicine exams.  I was so impressed by his experience, humor and deep concern for  addicted clients.  There's several streams of presentations so it's not possible to hear all the great speakers.
I was very thankful to have atttended Dr. David Marsh's presentation on the History of Methadone Treatment as it was so relevant to my work as a methadone doctor.  I'd just passed Dr. Gary Horvath from Doc Side Clinic in the hall.  Gary mentored me in Methadone Treatment when he wasn't off doing Iron man competitions.
Dr. Marsh's was instrumental in the establishment of Insite, the safe injection site in Vancouver. His presentation of the public health benefits obviously impressed the Supreme Court.  He continues to do research in his position with the University of Northern Ontario. He commented briefly on the Naomi research on heroin as an alternative for methadone in the small subcategory of patients who appeared to have need for this treatment after decades of failed treatments with all the orthodox approaches. Buprenorphine was being used in physician offices in the US and because these were so different from the regulated US methadone clinics it was questionable how much relevance the outcomes had to the very different opioid dependent populations being serviced by Canadian methadone clinics.
Dr. Krauss, Addiction Psychiatry chair at UBC and head of the Burnaby Mental Health and Addiction program presented the need for a truly integrated bio psycho social approach for the polysubstance addicted person with concurrent psychiatric disorders.  Coming from Europe he was truly disappointed by the neglect that these severely disabled patients experienced.  He spoke to the need to meet patients where they were, providing a range of services, as with any chronic mental illness.  Given his experience with the approach to care of patients in Germany , Switzerland, Norway and the UK, it was most interesting to hear how they'd achieved success with a much simpler and more pragmatic approach to some of the problems which had stymied doctors here. His compassionate learned approach to the problems of downtown eastside Vancouver provided a sense of hope to those present.
Attending were doctors and other health care workers, counselors, administrators, family physicians, youth service workers, forensic specialists, those working in  the jails and courts, representatives from various treatment centres and recovery homes,  psychiatrists and those already certified in addiction medicine by the Canadian Society of Addiction Medicine.
The conference continues all weekend and the atmosphere is so invigorating.  As Dr. Kraus said, to audience laughter, those attracted to work in the field of addiction aren't looking to become rich or be the next medical department head.  He said you don't have to go to Haiti or Africa to help the truly disabled you can serve patients with addictions in urban Canada.  Hearing him I was reminded of how Dr. Jack Hildes used just that statement to woo me to work with the University of Manitoba Northern Medical Unit. The 5 years I was associated with that program remain in many ways the time I felt best about being a physician and psychiatrist.
Dr. Marsh shared that a colleague had said that he'd thought himself the most stigmatised of physicians when he'd begun to work with HIV in the early years till recently he'd come to work in addiciton medicine and felt he was even more stigmatised and marginalized.
That said, the conference has provided so many great clinically useful ideas and not at all shied away from the tough questions that are day to day reality in this tragically human  field of chronic medicine.  I'm thoroughly enjoying this conference and delighted to see so many present.
When I first moon lighted as acting head of the Winnipeg Detox in 1985 I had no idea I'd one day be at a scientific conference with the bright and best and so many young health care professionals obviously keen and ready to tackle a problem too long ignored.

S.V. GIRI and Autumn 2011

Once again I'm spending alot of time on the GIRI.  When I'm not, I simply don't do the needed maintenance and renovations.  It took a real beating on the solo trip to Hawaii and coming back with Tom.  The mast was broken at the base on the return trip and the following summer Tom with Barry the welder and others restored the mast and hull to the standards the surveyor advised.  To do this the whole cabin had to be removed to avoid fire.  This was roughly restored and an amazing cleaning job was done by Joanne's company.  Jim has fixed the exhaust and skylights and installed a new Dickinson diesel heater. He's putting in a new galley stove when it arrives this November.  I've puttered as I do when I'm on board cleaning and fixing odds and ends. I'm rather pleased with the shower pump and foot switch I installed.  The head is working just fine with Tom having fixed the toilet and Jim having installed a new Electrosan.  I almost feel like my shit doesn't stink now. Certainly with the fully functional shower I'm doing fine myself.
Last night I cleaned the freezer in anticipation of the venison I've got coming from the butcher.  I confess it's not been cleaned in many months.  I have to check the batteries as well come to think of it, new ones being installed but it's been a couple of months since I checked the water levels.  There's always something needing doing.  I try to keep the boat shipshape. The survivalist in me wants to be able to go to sea at a moment's notice.  I've an alternative land escape in the RV and truck and motorcycles and ATV.  Partly I'm just a big kid with adult sized tonka toys. Alternatively my generation were affected by the Kennedy missile crisis.
Each day the boat is an experience. When I leave I have to turn off the through hull for the toilet to secure the boat despite the bilge pumps I have as back up. When I come home I have to turn the through hull again, and   start up the propane system to turn on the gas to stove and head water heater.  Then , these days I start the Dickinson diesel heater so the little flames warm the cabin up, the electric heater only keeping the temperature "English" and not "tropical' like my siamese cat, Angel,  and I enjoy.  Gilbert is not so keen on the heat but loves the boat with his best friend, cat. The two run up and down the dock together when the weather is good and I let them.
It's like everything is on 'manual' on the boat and I confess when I stay in a motel I appreciate the 'automatic' ease of modern living without concern about water usage, heat or thru hulls.  There's nothing like being on the water though and it's a small price to pay for the joys of maritime living. The best part is that this leads to my having the boat ready for those trips out to the islands when I can have the full joy of being at anchor after a boat trip.

Bahrain Doctors Tortured

http://www.bmj.com/content/343/bmj.d6417.
How can Moslems stand by and allow such barbarism to continue in the name of Allah?  Moslems venerate Jesus as the healer and claim their religion as compassionate.  Bahrain can only be an embarrassment to the followers of Islam.  The rulers of Bahrain  would imprison and torture physicians for providing medical care. Not just male doctors but women doctors as well. Have the ruling Al Khalifa forgotten that the civilized  wipe their arses with the left hand? It would only be fitting if neither Christians or Moslems would eat with them until they freed these physicians.  If this is how the Bahrainian rulers treat their physicians, the SPCA  (Society for Prevention of Cruelty to Animals) should invade their country on behalf of the camels who must surely be abused by these pathetic infidels.

http://www.guardian.co.uk/world/2011/oct/05/bahrain-medics-retrial

So the doctors and nurses are to be retried. Global opinion was utter disgust for the ignorance and spiritually bankrupt response of Bahrain to it's own healers.  I am praying for these doctors and nurses. I am praying too that the Bahraini leadership learn to not shit where they eat.

Morning Glory - the movie

I laughed and I cried. I laughed crying and cried laughing.  Rachel McAdams, Harrison Ford, Dianne Keaton make this film about a young producer trying to pour life into a dying tv show an unforgettable masterpiece.  Patrick Wilson and Jeff Goldbloom add even more to Morning Glory, a film directed by Roger Michell and written by Aline Brosh McKenna.