Psychosomatic Medicine

Pscyhosomatic medicine doesn't mean "it's all in my head".  It means rather that the 'head bone is connected to the toe bone'.  Without your head you'd not experience any medical condition. The fact is that all medicine and surgery is 'psychosomatic'.  By convention and the dualism of Greek philosophy and later Descartes people began to think of their 'body' as somehow disconnected from their mind.  Modern "mind-body" medicine tries to overcome this limitation. My hand is truly separate and different from my arm but they share a common nervous system, circulation and lymphatic system. Indeed the more advanced the medicine the more recognition of the interconnectedness of the parts.
I started my career with a surgical internship. I wanted to be an orthopod, to tell the truth.  I got waylaid by family practice in the country and northern medicine. It was in the thick of clinical work I saw the importance of depression, psychosis, drugs and alcohol, attitudes and beliefs to health.  I decided to study psychiatry with the purpose of advancing my understanding of bodily illness in many ways.  I learned a tremendous amount in psychiatry about disease in general and mental health in particular.  At times though the psychiatrists themselves were all too much in their heads.  Just as family practice was revolutionalizing to a greater awareness and understanding of community, family and the individual as those contriubted to physical health psychiatry was fleeing from embracing the whole realm of psychosomatic illness and instaed focusing on 'brain disease as if the brain was somehow floating disconnected from the body.
The Ericksonian Foundation based on the pioneer work of American psychiatrist , Dr. MIlton Erickson along with the Palo Alto School and other key centres of research was a place where I found a home a way from home. At the huge medical and psychological conferences of the Ericksonian Foundation in Phoenix I met others interested in the efrects of faith on healing, how exercise promoted health, nutrition and it's influence on mental health, and all manner of psychosomatic ideas far too advanced to be embraced by the increasingly rigid orthodoxy of psychiatry. I followed cardiologist  Herbert Benson, and Internist Bernie Segal's work with rapt attention. Later I'd love the medical magazine, Psychosomatic Medicine.
I would too often attend a psychiatric confrence and hear more about treating the 'brain disease' without consideration of the human holding the brain and how their mind was altered by disease, their relationships and their community.  Always I thought in 'systems' and interactions but I'd be frustrated by those around me who seemed to think that equations could only flow in one direction as if they had not studied biochemistry as I had.  I found the ecologists and community medicine doctors and more and the addiction medicine docotors were thinking in the broadests sense while not missing the details.
It's not surprising that I've ended up in addiction and trauma psychiatry with an interest in consultation liason neuropsychiatry.  Every organ in the body is affected by alcohol and drug abuse.  Alcohol increases throat and bladder cancer, diabetes, heart disease, depression and community violence as well as poverty.  Drug abuse such as crack causes micro infarcts, causes MRI changes in the frontal lobes, afffects immune systems, marijuania causes early psychosis which can persist as lifelong schizophrenia, as well as causing lung disease and asthma from the smoke inhallation. Heroin is as much a community problem as an individual problem. The opening of a methadone clinic in a community can reduce theft there by 25% or more saving the inhabitants of the community millions of dollars a year.  Yet addiction is a mental illness as well as a physical illness and a matter of public and community health.  I'm delighted to be among colleagues who while working for a 'brain' disease 'cure' don't seem to think in rigid isolation but rather see the issues in the microcosm and the macrocosm.
In consulataion liason and neuropsychiatry the wide ranging effects of head injury or crohn's disease, diabetes, cancer, or multiple sclerosis are not limited to the cellular damage or the initial injury. A head injury commonly becomes a life long disability no different than loss of a finger or limb while often concurrent mental illness affects how a person will recover from surgery.
Psychosomatics is medicine and it's surgery.  The idea that the body exists in isolation is long gone.  People with depression develop physical illness more readily just as the Rahe Holmes studies showed the significance of stress on body illness. Similarly people with bodily illness are more prone to develop mental illness. Patients with chronic pain from arthritis commonly develop depression.  The use of prednisone, a life saving medication, is commonly associated with psychosis and mood disorder.  People with infections commonly develop panic and anxiety.
All teaching hospitals have a consulting psychiatrist as part of the team of physical doctors who work in hospitals, medical and surgical, wards, because psychiatric issues arise so commonly among patients with physical illness. I was the consulting psychiatrist to a hospital and commonly called out every night on call to deal with delirium, dementia, grief and violence.  I enjoyed one old codger who was going into DT's the night before his surgery and my psychiatric intervention was to make sure he had enough alcohol through the night to stop him from seizuring.  The surgeon and anesthetist were very thankful to have a psychiatrist on board.
I'm a medical doctor first, psychiatrist second.  I also had two years of residency in community medicine and public health so I not only see my patient's brain connected to his body but I also see my patient connected to his family and community. Increasingly in my work with addiction and with patients who have been in and out of jail I see that the 'system' is the old fashioned jailhouse punishment mentality that exists outside the shining light of the 'drug court'.  Yet few of my patients are fortunate enough and rarely early enough to take advantage of that breakthrough in the all too often dinosaur thinking of the criminal system.
Just last week I met with a group from the courts who were shining lights but I could see that they had had years of the frustration I'd had working with the entrenched stupidity of people trying to fight today's wars with yesterday's ideas.
I was delighted to work with a judge in Saipan who saw so clearly the need for the New York solution for chronically violent mentally ill to be discharged to the community only on condition of being on long term injectable antipsychotics. Like the drug court which uses urine testing for drugs as a conditon of freedom these 'systems' are working now with psychiatrists who are trained as much in psychosomatics as community to achieve what is best for the patients and society. Often an ethicist and leaders of the patients failth community are brought together to ensure that an individual decision doesn't lead to an abuse of human rights in general.
At times I miss the idea that "Mr. Jones is the 'kidney' in hospital bed 3" or Mrs. Smith is the 'mental case' in hospital bed #4.:  It's always easier to think like administrators and reduce people to nazi numbers but the fact is I like people as people with all their diemensions. Increasingly too it's the spiritual dimension that moves me. That said I'm thankful for enlightened administrators who with great humanity can actually move the ship of state away from the rocks in a storm.
People are not only connected to community but it's been said 'anxiety is a measure of your distance from God".  I don't think of God as the Santa Clause tyrant on the cloud. I rather like Bishop Spong's debunking of the Christian God and the Jesus Convention work on the History of the Bible.  God in a 'spiritual' sense is about all those imponderables.  What do I believe is my 'purpose'. What are my thoughts about the meaning of life. It's not that there's an answer to these questions in general but how I answer them specifically is critical.
Just last week I met a depressed woman who said she thought the world was going to end so there was no reason for her to even think of marriage and children. Yet that's what she had wanted till she'd embraced that pseudoscience of nihilism.  Her noncompliance with medical regimen, refusal to care for herself and refusal to take medications for her illness was tied to the central questions of her life.  I think that's where the 'spiritual' lies.  It's all those questions and sometimes arbitrary working answers that get us through the night. It's not that 'prayer' is right or wrong but it can work quite amazingly. just as confession, asking for help, meditating, doing yoga, chanting, singing hymns, going to a concert, dancing can all contribute to health. It's the wholistic that's God or the Good in life.
I once wrote I didn't want someone to give me a bag of whole grain riice when I needed admission to an intensive care unit but I knew then that eating whole grain rice, as just one example, could help me avoid admission to an ICU. The more we learn about chronic illness the more we learn that they are psychosomatic illness of lifestyle. It's time to embrace the idea that the head bone is connected to the toe bone just as the toe bone is connected to the headbone as we live in relationship with all around us.

Ballet BC - Three Fold

Another sensational night at the ballet.  Diversion by Robert Glumbeck was original and intriguing with extraordinary modern dance.  Walter Matteini's Parole Sospese was downright weird in the best of way. Right out there.  Existential wonderland.  Simone Orlando's Doppeling was retro at it's finest.  Normally I'm simply enthralled by Maikalla Wallace, Alexis Fletcher, Dario Dinuzzi,  and Gilbert Small.  I love the wisdom of their experienced dance interpretation. Yet tonight all the members of the company stood out.  Rachel Meyer was so fresh, Andrea Pena passionate and Alyson Fretz sophisticated in a particularly European way.  Connor Gnam and Alexander Burton were particularly outstanding.  Rachel Prince, Peter Smida, Maggie Fogeron, Livona Ellis, Jed Duifhuis, Chisto Ide, Daniel Marshalsay, and Darren Devaney all were a delight. I'm sorry I can't put faces to names with some of the older and some of newer members because all their pas de deux, leaps and lifts deserved individual mention after tonights superb dance performance.  I truly think that Bach would love what Simone Orlando did for his timeless music. Kate Burrows, Linda Chow and Ina Broeckx's costume designs were genius. Artistic Director Emily Molnar continues to inspire. We are truly blessed by her and Executive Director, Jay Rankin's vision.  Tonight Fasken Martineau was celebrated as Season Sponsor.

Opioids for Chronic Pain - CSAM Position Paper 2011

On Nov. 5, 2011, at the Canadian Society of Addiction Medicine annual scientific meeting, Dr. Ronald Lim and Dr. Nady el Guebaly presented on CSAM's new position for use of opioids in chronic pain.  I took some notes and compikled this blog based on those simply to share the highlights of the discussion. This is a very hot and controversial topic that affects the majority of physicians in clinical practice.  I was very thankful to see that concerns of patients and clinicians were so well addressed in this complex field.

This position paper was developed in response to

1. concerns regarding patient and public safety risk from opioids
2. Rising rate of rx opioid abuse
3. Rising rates of illict use of rx opioids

https://www.cpsbc.ca/about/programs/controlled-prescription-program/prp-guidelines

NOUGG - National Opiate Use Guideline Group was the research team  set up with physician/epidemiologist, four physician researches, and research librarian to study research to date and bring findings to the National Advisory Comittee

6,580 studies identifed

184 met inclusion criteria

Concerns regarding patients and public safety were raised.

Canada recorded rx opioid consusmption increased by 50%

Canada is current the third largest opioid analgesic consumer per capita

Dhalla 2009 showed that 1095 overdose death in Ontario, 56% had been given opiod prescription within 4 weeks before death

Study of oipiod depent patients, 37% receieved their oidiod from physican prescriptions

Kuehn 2009  noted increase in rx and increase abuse, serious injuries and overdose death

In patients with history of substance abuse

prevalence of aberrant drug related behaviour 11.5%

urine drug screens with illicit drugs 14.5%

Investigation of the evidence of opiod efficacy was best for the following:

diabetic neuropathy

peripheral neuroptahy

postherpetic neuralgia

phantom limb

spinal chord

In other conditions the evidence was mixed or absent:

Fibromyalgia - no randomized trials of strong opiods

of the trials, tramadol, shown best.

Osteoarthritis

small benefits outweighed by increasde adverse affect

neuropathic pain - subjective improvement was noted but not not that significant when compared with  functional status. Patients felt better but didn't appear to 'do' better with the subjective benefit.

Migraine, tension headaches

opioids not indicated

A major recommendations was associated with discontinuing opioids:

-opioids should be tapered and discontinued if patient’s pain remains unresponsive after trial of several differnet opioids.

This was a critical piece of information given the clinical tendency to start opioids and believe they are beneficial when they haven't shown benefit and then leave them in place for fear of addressing the issues of discontinuance.

Further recommendations included the following:

definition of addiction in context of pain treatment should be clarified and concerns should clearly be raised if the following are noted:

1)Continued opioid use despite adverse consequences

2)Loss of control

3)preoccupatins with obtaining opioids despite adequate analgesia

4) denial of a problem

There were very important recommendations regarding physician training in this regard, consensus being that physicians needed specific training and that specific training would go a very long way to reducing concerns re safety and abuse.

Physican prescribing should be appropriately trained  and physicians should ,perform documentend compreshensive training

Further, "medical legal consequences should be muted". If physicians were supposed to prescribe opiates for severe and chronic pain in appropriate situations they should not face overwhelming negative consequences for doing what was best for the patients or else physicians would have no choice, really but to feel that they were getting a mixed message in which 'ommission' would be rewarded but where 'commission' would be punished.

Opioid prescribing for chronic non-cancer pain

M.Kahan, R. Lim, N. el Guebaly Sept 2011

1.Careful patient selection

2.First line opioids - WHO pain ladder

3.Dose titration - should improve function, reduce pain by at least 30% (10 pt), mostly well below the 200 mg morphine oral range

4.Overdose prevention

5.Screen for addiction risk

6.Opioid tapering - lack of response to high dose

1. Management of high risk addiction
2. Management of suspected addiction
3. Treatment options - structure opiodi therapy, opioid agonsits

This will be published in the Can. Journal of Addiction Medicine

The discussion continued with recommendations for Public Health, defunding the 80 mg Oxycontin, and de linking Buprenorphine prescribing from Methadone, being addressed.  The discussion, in fact , was rather exciting suggesting participants not only appreciated the presentation but working themselves in this difficult area had many questions and ideas to share.  It was clinically very elucidating.

I have survived waking up another day

I have survived waking up another day,
The old car with a hard start on a cold winter morning,
The ache and pain of lost youth,
The coughing sputter of engine refusing to turn over,
Choking, gasping, sucking air
Praying, begging, rolling over,
Fighting through the worrying dog and cat,
One wanting food, the other needing to pee,
Toilet pit stop bringing certain relief,
Dressing a chore, especially the shoes,
The overcoat barely breaks the chill wind,
But the dog's ecstacy uplifts.
And walking,
The old car gathers steam,
Takes the corner like a pro,
Follows the lead dog,
Leaning into the wind,
Making the coming home turn,
The dog having done his business discreetly,
Saving me the effort of bending and picking up,
My engine veritably roars in the home stretch,
Imagining the smell the brewing coffee.
After a shower, dressed in work clothes
I'll look like something new and fresh,
No one would believe I barely survived this morning.
How easy it would have been to roll over and gone back to sleep
Hiding in that other world, uninterrupted
Except for the occasional nightmare, these days.
The cat now eats her breakfast
And the dog is looking relieved.

Bushnell -Fusion 1600 ARC Laser Rangefinder Binoculars

Bushnell - Fusion ™ 1600 ARC 10 x42 mm [201042] > I bow hunt and rifle hunt and I'm a blue water sailor.  All my scopes are Bushnell. I've been really quite satisfied with Bushnell binoculars especially considering the price. When the Bushnell - Fusion Arc became available  I bought them. I'd read about them for a month or so before I saw them in 100 Mile House hunting outfitter store.  They lived around my neck the duration of this season and will accompany on my sailboat as well.  I'm delighted with the clarity and magnification of the binoculars. They're as good as any I've had for hunting letting me see well at dusk and dawn. What's fascinating is the range finder. There's enough features for a cyborg but what I simply like is pointing at something estimating the distance and then finding out the exact amount. I've routinely off 10 yards either side of an object. The first time I estimated an object was 100 yards it turned out 85 yards. Now I'm training my vision. It's a lot different being in the woods and on trails than at the range. I actually set my targets up more correctly. I expect these binoculars could even improve my golf game.  So I just wanted to share that as far as 'boy bling' goes, these have really done it for me this year. 

Attack on Leningrad - Movie

In spite of myself I watched a disturbing human drama of historical significance. I picked up the DVD kind of thinking I'd enjoy watching some fast action plane fights done up Russian style. Instead I weeped at the terribly touching story of two women, others, and the children.  There were planes and tanks and bodies lying dead to be eatten in the seige of Leningrad.  But there was also this moving moment when a father tells his departing daughter, "Don't give up."  Action packed, for sure. but spilling over with humanity as well.  Not at all comic book or cut out people. Acting so real by Mira Sorvino, Garbiel Byrne and Armin Mueller--Stahl and Olga Sutlova.  In the Nazi seige a British Journalist Kate Davis is presumed dead only to be rescued by Nina a member of the Soviet militia.  With papers lost and declared dead Kate stays starving and surviving with Nina's family.  Alexander Buravsky is the director.  The movie was so much more than I imagined.
In the end I felt like I'd just watched Dr. Zhivago expecting an episode of House MD.

Merrit B.C. Hunting with Luke and Gilbert

I began Veterans Day by phoning my father to thank him for the peace and liberty I'd experienced in my life thanks to his service in the Royal Canadian Air Force.  At 92 he'd slept in and thanked me saying, "I'd better get up and see what's going on today."  I headed out then with Gilbert to pick up Luke for the last weekend of moose hunting in area 3, Thompson. Merrit BC was our destination.  Luke had his gear ready at his home in Kitsilano so that was the briefest of stops be fore we headed over to North Vancouver to pick up my gear.  Then it was a road trip.  Gilbert loves the fast food meals stops on road trips, always getting his single fried meat paddy as part of the hunting crew.
In Merrit we made our basecamp at the pet friendly Ramada Inn.  We were out in the darkness and on site hunting before dawn. We were back at the hotel after dark.  We did everything by the book and had the drill down to a t. The only trouble was the moose didn't show. We did see a 2 point buck which would have been easy pickings except it was 4 point buck only season and Gilbert began barking shouting in dog, "Don't shoot, it's only 2 points."  Before we could understand his message he was getting shouted at. The deer departed.  We never saw a single moose. Tracks of deer and moose were everywhere.  But what we did see were wolves. Incredible animals. Up close and unpleasant.  We saw 4 altogether.  Big black ones that ran at the sight of us.  Luke saw a bobcat.  I shot a grouse.  It was ATV and Ford F350 truck heaven.  It was too cold for much sitting in ambush.  So we stalked with fresh snow covering the sound of our footsteps.  Luke rode the Polaris Sportsman 500 ATV loving it.  I had a cold so did a lot of driving around coughing and sneezing in the heated cab of my Harley Davidson edition Ford F350 diesel truck.  I'd tried sitting in the cold but began coughing so quickly retreated to the warmth of the truch hanging out scoping likely areas with Gilbert as my companion. Then Luke would rejoin us and Gilbert would be ecstatic.  At night we watched warm movies and westerns.  It was a great weekend that could only have been made better by shooting a moose.