Driving and Marijuana

With the legalization of marijuana fast approaching (The Government of Canada is now saying “sometime this summer”), it was only a matter of time until one of my patients asked this question:

“Dr. Beck, how much marijuana will I be able to use and still drive?”

“I didn’t think you were driving yet.”

“I’m not driving officially, but I’m going to get my G1.”

“So, you don’t even have a G1 and you’ll be too young to buy marijuana legally, but you want to know how much you can use and still be able to drive. Is that what you’re asking me?”

“Well, when you say it that way, it makes it sound like I shouldn’t consider this at all, but I’d like to know.”

In fairness to this young person, I should say that both youth and parents are asking me similar questions, so I decided to see what I could learn about driving under the influence of cannabis. For the purposes of preparing this short review, I used three main references. One reference is a comprehensive report entitled Developing Science-Based Per-Se Limits for Driving under the Influence of Cannabis: Findings and Recommendations of an Expert Panel. The report was written in 2005 and includes a thorough summary of the Empirical Research on cannabis and driving. I checked with the Medical Librarian at my hospital to see whether they could find a more recent and as comprehensive report. Since they could not, I highly recommend this excellent, comprehensive reference.

I also reviewed the research of the American Automobile Association and the Canadian Automobile Association which, while not as comprehensive, is much more understandable for most readers. I will use these a references for most people who ask me for information.

Finally, I regularly review the Government of Canada and the Government of Ontario websites for updates on the legalization of cannabis. The Government of Ontario has determined that the Ontario Provincial Police will use Oral Fluid Screening Devices for roadside testing of cannabis. There are some concerns regarding the reliability of the devices and, since the Expert Panel Report recommended blood levels only as a means of measuring cannabis levels, it seems that cannabis will be introduced without clear guidelines regarding impairment comparable to Blood Alcohol Levels.

When discussing driving safety while using any substances with parents and youth, I always stress that a person should never drive if they feel at all affected by what they have ingested. As most people know, the extent to which a person can feel affected by a substance they ingest can vary widely from person to person, but, if an individual is being honest with themselves, this can be a very reasonable guideline.

For those wanting something more precise related to cannabis use, I did determine a straightforward guideline from the information in the Expert Panel Report. The report reviewed the results of all the epidemiological studies related to driving and cannabis use and performed a meta-analysis of the experimental studies.

In reviewing all the studies, the panel reminded the reader that there are 3 phases of impairment due to cannabis use. There is an acute phase, during the first 60 minutes following smoking cannabis. Then there is a post-acute phase that presents 60-150 minutes after use. There is, finally, a residual phase, occurring 150 minutes after ingestion. The panel members concluded that most studies showed that the impact on driving skills is minimal during the residual phase. This means that, depending on the amount of cannabis smoked, most people will no longer be affected 3-4 hours after smoking 20 mg of cannabis. This is the basis of the guideline I am providing: Don’t drive for 3-4 hours after smoking cannabis, depending on the dose. (Note: The studies also showed that there are differences in the timing of impairment after smoking cannabis, as compared with oral ingestion. Impairment relation to oral ingestion of cannabis peaks 2-3 hours after consumption, while impairment after smoking cannabis peaks at one hour.)

I like this guideline because it is clear and straightforward, although I am also reminding the young adults in my practice that most of them would never go out for an evening during which they might drink at all without a designated driver. My own practice suggests that, as far as alcohol is concerned, most youth I know would never drink and drive. Why not also have the same “designated driver” system when using cannabis?

As I review these studies and reports in conjunction with the information being provided by the federal government, I continue to be concerned about the lack of foresight in legalizing cannabis in Canada. It seems to me that the amount of time needed to ensure the safe legalization of cannabis might have been more accurately predicted. If the timing was not well-managed, can we really be sure that other aspects of legalization will be handled safely?

(photo credit)

Book Review: The Morville Hours

It is only within the last two weeks that my garden has sprung to life. With the bitter, and very long, winter that has just passed, evidence of spring in the garden was late arriving and, longing for fine weather, I found myself contemplating one of mt favourite garden books.

The Morville Hours by Katherine Swift was published in Great Britain in 2008 by Bloomsbury Press, which was the edition I read. According to the frontispiece, Swift was a rare-book librarian in Oxford and Dublin. In 1988, she became a gardener and writer full-time, with her articles on gardening receiving wide distribution in the gardening press.

At the time she changed careers, Ms. Swift moved to a new home, the Dower House at Morville, in Shropshire, England. The Morville Hours is an account of how Swift built a garden in her new home. As she tells her account, the text follows the meditative path of the Hours of the Divine Office. The Hours of the Divine Office is the set of prayers that mark the hours of the day. These are ancient Christian prayers, common to both the Eastern and Western rites. The book that contained the prayers was known as the Breviary and originated in medieval times. Swift calls it the “bestseller” if its day. (Page viii)

As the Breviary was meant to be used for meditation, Swift meditates upon her home, her garden and her life in this book that is at once peaceful, but also a provocative reminder of our need for rootedness. Here is what she says about her life at Morville:

“And gradually I began to see that in the Hours – with their joyful Te Deum and litanies of praise, their Office of the Dead and Penitential Psalms, their despairing De Profundis and final serene Nunc Diminitus – was reflected the arc not only of a single day or a single year, but of a whole lifetime, with its trajectory from darkness into light and from the light into the darkness once more.” (Page 11)

For those who never had a liberal arts education, this is a work of literature that will educate you about some of the more important aspects of that education. Illustrated with woodcuts, filled with poetical references and scenes from her own life, this book can be read again and again at many different levels.

I reread my copy in corners of my garden, imagining myself to be any one of the persons that Katherine Swift is: an accomplished gardener, a classical scholar, a skilled writer – or a woman who has examined the her own life with compassion and found her way home at last.

(Note: My copy of The Morville Hours Is the 2008 Bloomsbury edition.)

From Bedside to Bench

During all my years of practicing medicine, I have been close to research in the institutions where I worked. I have admired and assisted clinical researchers, but I had never felt inclined to join their ranks. When I became the Clinical Director of the Youth Program two years ago, however, that changed. With this new role came the task to promote research and to become more personally involved in the research being conducted in my program and institution.

It is remarkable how much research is conducted in a university teaching hospital, with little funding and most research being conducted off the corner of people’s desks. Most of these researchers are earning their living from their clinical work, with next to no additional funding. Often the only additional funding they receive covers costs related to materials for research and a few hours from a research assistant. It is not unusual for physician researchers to be self-supporting, receiving no direct compensation for this work. This is my experience in psychiatry, but I suspect that it is not much different in other medical specialties.

Much of the research conducted in the clinical programs in which I work is to benefit our programs and our patients, first and foremost. We ask each patient to complete surveys and simple diagnostic measures before and after all programs, in some cases after each session, so that we can be sure that there is value to the programs and therapies we have developed and that we use. In many programs that we are developing, we ask for feedback after each session. For example, if we are starting each session with a mindfulness exercise that no one finds helpful, then we change exercises. All this data provides us with valuable information about the profile of the patients we are treating. It also indicates the type and severity of the conditions being treated in a tertiary care treatment facility.

As I began to consider all the data we have available that patients have given permission for us to use and analyze, I began to consider that, even when I worked as a psychiatrist in private practice, I had a great deal of patient data at my disposal. Occasionally, when a situation I had managed was very unusual, I would discuss with a patient and their family the possibility of sending a short communication about the case to a journal. I had no one to advise me on the process. I had to negotiate and consider the ethics of the situation on my own with the patient and their family. Often the patient and the family had considered their situation to be unique. They were eager to participate in this minimal research process as a specific case discussion to benefit other patients and families who might find themselves in a similar situation.

The minimal level of funding available in universities and the complete lack of funding available to physicians in private practice to pursue limited clinical research underlines the shortsightedness of our single payor. Imagine if research were promoted by Provincial Ministries of Health in Canada, to the extent that expertise and funding were readily available to Primary Care and other specialists in the community, what we might learn to improve best practices in Canada. Imagine if the funding in Alternate Funding Plans was sufficient that every physician in our teaching hospitals could be involved in research without financial penalty, what we might learn about secondary and tertiary care.

An example of the kind of research that is possible when the payor supports it is the study conducted by the United States Center for Disease Control, supported by Kaiser Permanente, is the Adverse Childhood Experiences Study. I learned about this study when I was researching (unfunded, of course) other data we might like to collect in programs. It is “one of the largest investigations of childhood abuse and neglect and later-life health and well-being”.

This is the kind of work we could be doing across Canada. I could not find any evidence of this research, although I would be relieved to know that I was wrong.

 

Book Review: The Weekend Effect

Ironically, I read the first two chapters of Katrina Onstad’s The Weekend Effect: The Life-Changing Benefits of Taking Time Off and Challenging the Cult of Overwork over short periods crammed into an especially busy month. I read about the results of her research addressing the question “What is a weekend?” on weekends with limited personal time. Then I rushed through a chapter outlining both how workers have gained and more recently lost this leisure time on weekends during time I had borrowed from other tasks and commitments. I was, in effect, a real life example of the overcommitted professional whose weekends are often spent working that Onstad describes. I would not be the only person I know to see themselves in her descriptions. One of the main concerns Onstad raises is that many of us willingly give up our weekends to work.

I read the last few chapters in very different circumstances. Last week, I took five days to go on a writing retreat. Located in Northern Ontario, mostly out of cell phone range, and with limited internet, I was forced into a situation with only limited capacity to work online. With large blocks of time to read and write, Onstad’s message became clear. Our minds and bodies need time away from routine and from work. As both my mind and body slowed down, my concentration improved and this well-written, well-researched book became a road map for me to a different kind of weekend, a weekend filled with renewing relationships, enjoying nature and appreciating the beauty around me.

Onstad’s book contains that essential element of a good creative nonfiction book: exhaustive notes on the research she completed. These are detailed enough that the reader can find her sources and their own work. From all this detail, anyone can realize the dream of having resting, relaxing weekends – weekends free from work and other travails. I completed the book in a setting embedded in nature, on days devoted to art and I am now committed to making better use of my leisure time.

Remember this saying,” No one ever died wishing they’d worked more.” (Attributed to Senator Paul Tsongas.)

Have a good weekend!

(Note: I read the 2017 Harper Collins paperback version of The Weekend Effect: The Life-Changing Benefits of Taking Time Off and Challenging the Cult of Overwork.)

A Raincoat for Grief

Two weeks ago, I took my usual Saturday trip to Halifax to see my sister.

I leave my home at 5:30 in the morning. I board a plane. I arrive in a city 1600 kilometres from home. I drive to a nursing home and spend the day with my sister, listening to her talking about her life, listening to her talking about her death. Then I travel backward and, at the end of the day, I am home in time for dinner.

I have cornered my grief into one day of the week. I get up in my own bed and then sleep the same day in the my own bed as if it has just been a long day. I am managing. My sister is always happy to see me. I am managing.

Except…except that, I am beginning to feel reality sitting next to me on the journey. I know this because two weeks ago, I took my raincoat with me. The forecast was for rain at home in Ottawa and for rain in Halifax. I might need a raincoat. I might need a raincoat even though I am dropped off and picked up under the plexiglass awning of the Ottawa airport. I might need a raincoat even though I never have to leave the airport building to get a car in Halifax. I walk 50 metres from the car into the nursing home. I come back the same way.

But I am travelling 1600 kilometres from home. It will likely rain in both cities. I need a raincoat.

For the past year, I have visited my sister at least every month and she is dying. She gets weaker every time I see her. She is getting more tired, and more and more often she talks of dying. I bring books to read that she loves, I send flowers – she loves to get flowers – and I bring her favourite cookies and scones. I am managing.

But this Saturday when I see her, my sister is crying. She talks to me about dying. Cookies and stories and flowers do not help. I put my raincoat in her closet in her room.

The grief is escaping from its corner. All the raincoat can protect me from is rain. I hold my weeping sister in my arms. I pray that she is managing.

At the end of the day, I walk the 50 metres to the car with my raincoat over my arm. The rain is pouring as my plane approaches Ottawa. I might need my raincoat.
I am managing.

(Note: I have developed this post with the assistance of writing group participants at #HarvardWriters2018. They have been an inspiration to me and I hope that this post captures some of their advice.)

Book Review: Hunger by Roxane Gay

I read Roxane Gay’s memoir about her life as a “morbidly obese” person in America in one day, tears streaming down my face on two airline flights and in 2 airport lounges. I could not have stopped reading. It was as if I believed that somehow, by reading her memoir, I might be able to somehow tell her, “You are worthy.” This book forces the reader to confront their own beliefs about body size and and their own prejudices.

As a doctor, I believed that I knew something about obesity, especially since I am overweight myself, but this book reminded me that I was wrong. At the outset, Gay tells the reader:

“People see bodies like mine and make their assumptions. They think they know the why of my body. They do not.” (page 5)

I learned from this book that not only do we misunderstand other’s bodies, but we may even misunderstand our own. Gay is brutal in her self-descriptions and the reader is caught in that brutality, pushed and dragged into the realization of the degree to which we misjudge obese people, skinny people, any people. The more we judge, Gay reminds us, the less accurate we are. In fact, we don’t judge – we misjudge. Can you truly get rid of your assumptions? Ever since I have read this book, I doubt that I can.

The other important link we learn about in Hunger: A Memoir of (My) Body is the link between sexual assault and obesity. This very good article from The Atlantic summarizes the research very understandably and is a good resource for anyone wanting to understand the research.

I admire Gay so much for being able to tell her story. I cannot imagine exposing my own pain to the world as she has done. I do not think I would ever have this much courage. This is, however, a very important book because, after reading it, only the most heartless would not be able to understand what obese people endure.

I do not think I could read this book twice. Even after looking through it to prepare this review, I am emotionally affected. I could not read this book again, but I am very glad I read it once.

(Note: I read the Harper Collins 2017 Hardcover edition of Hunger: A Memoir of (My) Body.)

A Primer on Gender

I am bewildered by the various gender designations currently recognized and described. As a psychiatrist who sees primarily adolescents, I must be able to understand what a person means when they tell me that they are non-binary transgender or two-spirit.

Gender and gender roles were so restricted in my adolescence that when I wrote an essay in Grade 8 on why I might like to be male, I was given a very low mark and told to write a make-up essay. I was completely naïve and totally bewildered. I wanted comfortable shoes and comfortable clothes and not to be treated like a freak for getting better marks than everyone else in my classes. Fast forward to the first time a young person told me during a clinical interview that they were pangender and you will realize, as I did, how much the world has changed. At the time, I dutifully wrote down the term and hoped it wasn’t critical to the diagnosis, although I suspected it might affect treatment. That was three years ago. Today, I ask my patients who are still contemplating gender identity better questions and direct them to resources that might help them consider this.

It is not only youth who are recognizing gender differently. The Government of Canada now allows citizens to use X on their passports for gender, rather than female or male. As it is now accepted that recognizing these gender differences is the standard of care, let me outline the resources that I have used to be more aware of these changes, which affect clinical care in all disciplines.

At the most basic level, all clinicians are expected to provide a gender inclusive environment in their offices. The Gender Spectrum website has some of the best resources to do this and I refer to their material again and again. Remember that, as a person ages, both when they are young or as an adult, their understanding and acceptance of their sexuality and gender can evolve or change. In a world that tries to keep human beings in easily defined categories, it can be difficult to figure out how to characterize your gender. The tools at Gender Spectrum may help both a youth and their family to better understand gender identity.

Many struggle to accept this evolution in gender identity, but acceptance is widespread. Facebook provides its users 70 possible gender designations. New York City officially recognizes 31 gender identities – my research suggests that this is the most designations of any government worldwide. Many governments, including Canada’s government as I mentioned, have begun to allow citizens to put “X” on their passports when they do not identify as either female or male.

Parents of non-binary youth worry about providing the support their child needs. They may have mixed feelings about their child’s sexual identity. Their hopes and dreams for their child may have been based on their gender. Even though many people are more accepting of non-binary identities, many are not. Far from accepting, many are downright hostile. Most non-binary youth that I see have suffered for identity. This is what I remember. It would be much easier for them to identify as male or female. If they can’t, and have suffered because of this, let’s not be the cause of further suffering and exclusion.

(Photo Credit)