Opioid Crisis 2018

There were 2861 apparent opioid-related deaths in 2017 and that number is expected to increase to approximately 4000 deaths in the coming year. The question is: Can this number predict at all how many new resources will be needed to improve the prevention of opioid-related deaths? Will we be able at least to stem the tide of what seems to be a worsening situation?

The data collected by the Government of Canada should be causing alarm in Canadians, but I wonder if we are becoming immune to alarming headlines. I am personally feeling overwhelmed by everything that I ought to feel alarmed about so, as my obsessive little way of managing, I am going to try to manage one or two alarming things that are problems that will affect my practice and the programs in my department. The opioid crisis is one of these since it is quickly becoming a big problem for those of us working in youth mental health.

Let me tell you what alarms me about opioids in youth psychiatry. First, consider that there are 16 opioid poisonings daily in Canada that lead to hospitalization. That is a 53% increase in hospitalizations for opioid poisonings over the past 10 years. Of that increase, 40% of the hospitalizations have come in the past 4 years, since fentanyl began to be important as a painkiller and drug of abuse in Canada. Of the opioid-related deaths in Canada analyzed this year, 74% have involved fentanyl. The 15-24 year old age group has the fastest growing rate of both opioid-related deaths and opioid-related hospitalizations. Also, an analysis of the hospitalizations shows that 31% of these are related to a suicide attempt. The fentanyl reaching Canada from China may be used more for a suicide attempt than for any other purpose – not that I believe there is any good purpose for it! Globe and Mail reporters Karen Howlett and Andrea Woo have done some great work on fentanyl, and I urge everyone to read their articles.

With so many youth suicide attempts linked to fentanyl, the public health response must reach out to youth directly. Here in Ottawa, Ottawa Public Health has developed a program for schools, which is a good step. Other Canadian cities are doing the same, and yet this crisis is still expected to deepen, as if there is no way to stop, or even halt, the burgeoning mental health crisis.

I believe that it is time to ask young people in Canada what more can be done to improve their mental health, especially since we do not have time to develop the system needed to treat their mental illnesses. The world that our young people live in, that drives them to suicide, needs to change but we need to ask them what would help.
For example, it is not uncommon in psychiatry for us to relegate patients with substance use disorders to their own little corner, saying that they must manage this condition before the mental health condition can be managed. Honestly, so many youth with mental illnesses are now doing their own medication trials with whatever substance they can find that this no longer makes sense. I can write Prozac prescriptions hoping they’ll be used but it doesn’t help when the fentanyl can be shipped across the country by Express Post. See the Globe and Mail reference if you think this is an exaggeration.

It makes more sense for all of us assessing and treating mental illness to just accept that most of our patients have Concurrent Disorders. It is also time to acknowledge that fentanyl, the flagship drug of the opioid crisis, is now commonly used to stave off the symptoms of mental illness and, if that doesn’t work, to kill yourself.
(Note: Concurrent Disorders is the term given when a patient has both a substance use disorder and a mental illness.)

I asked at the outset whether the numbers of opioid-related deaths in Canada could be used to predict what resources will be needed to prevent these deaths. In fact, all this evidence tells us, and what we can see from the British Columbia and Alberta experience where the crisis is further developed, is that we can never be ready for the impact of fentanyl.

In the world of youth mental health, the opioid crisis is an invisibility cloak for the mental health crisis, and most of us do not make the mistake of confusing the two. In my little corner of the world, I am going to be trying to convince everyone I can of the need to avoid fentanyl and opioids in general. I am going to try to catch whichever overdoses I can. I am going to support every single addiction and rehabilitation measure governments see fit to introduce. There will not be too many resources – the evidence is that there will never be enough.

(Photo credit)

The Curator

I am desperate to understand why I cannot keep my desk clear. It is as if the objects that accumulate there have a life of their own.

At Christmas, I took two weeks off. One snowy day in late December, I sorted through the piles of paper and organized the piles of books. By the end of a full day, I had reduced the pile of books to the one book I was currently reading and the paper to one two-inch pile.

It is now February. There are now six books on my desk. The pile of paper is now four inches high and there is a smaller pile of “urgent” paper beside it.

What is “urgent”? The Annual Report of my church for next week’s vestry meeting is “urgent”. The incorrect reservation for my trip to London, England in May Is clearly “urgent” since it must be changed. The details on how to set up a simple crystal meth lab using readily available household supplies are on the “urgent” pile because I need to check whether one of my patients could have done set up such a laboratory. I realize that this sounds far-fetched, but the situation is real and could be “urgent”. The “urgent” pile is every item that must be addressed quickly.

What is on the other four-inch pile of paper? The book review for a textbook that I’d like to buy, this month’s edition of my favourite literary magazine, and the newsletter for the Osler Library have all crept onto this pile and snuggled in between recipes, newspaper articles and Aunt Stella’s letter. The last item may need to be moved to the “urgent” pile to be answered in decent time.

There is also the pile of books, of course, but, since these are all library books, it seems to me that they don’t count as my pile.

I am a psychiatrist. I spend entire days helping others figure out why they behave as they do, but I am completely crippled by one small housekeeping task. I have read more self-help books and consulted more websites on the topic of office organization than I ever thought existed. There are so many books and websites on this topic that there are lists of the top websites and books about organization. Most of these lists rate the top ten books or websites on organization, but one poor reviewer couldn’t even declutter the list and so she has listed the “Top 15 Books on Organization”.

The problem with these references is that they consider all of my paper to be “clutter”. The references consider my papers and articles and objects to be unnecessary, even a hindrance, for productive living. All these experts look upon the elimination of these piles of paper and books on my desk as a housekeeping task. But, as I said at the beginning, the objects and paper have a life of their own. These lives begin in my imagination. They are the offspring of my wish for my life to be more than I can manage. I am not ready to eliminate some of the tasks I have assigned myself with these piles of paper so that I can “declutter”. I want to hold onto the people, events, or activities that each book or piece of paper or object represents.

Consider the life each of these items has. Consider my aunt’s letter. I know that when my aunt dies, the letters written in her hand, using the phrases she used, will bring her to mind more vividly than my memory alone can do. Recipes are often collected less for me than for my husband, or my children, or a friend. Knowing how to set up a crystal meth lab will illustrate to a young man with a bad drug habit that I am perfectly aware of how risky his life has become.

I consider each of these objects to be artifacts and I am a curator of sorts, acquiring in piles that must be sorted the items necessary for a retrospective, personal exhibit of this current era in my life. When I have time, and when my aunt is much in my mind and I feel like speaking with her, I will take the letter she has written and answer it. There must be time to consider what she has said and respond. Then I will save the letter in the correspondence file I have of all her letters to me. This file is truly alive and so it is no wonder that the pieces of the file insinuate their way onto a pile on my desk before they get to the place where they will finally live. They want my companionship.

Similarly, the recipes I save are eventually scanned, or found online and saved to an online recipe collection, ready to be the main dish in a family birthday celebration or a special treat for a friend. This collection has become so like an exhibit that my family and friends ask for regular access to the collection or for items from it.
Finally, such ephemera as the instructions for a crystal meth lab are meant to be temporary exhibits, to be used in the service of a single event or circumstance. If recorded at all for posterity, this research will be documented as a footnote in my patient’s electronic medical record.

Perhaps this vision of myself as a curator of small exhibits, shown only to a limited public or for personal enjoyment is too grandiose. Perhaps it is just my excuse for the fact that I never seem to be able to keep my desk uncluttered. But I know that I am not unique in this curatorial style. I am suspicious that the organizational experts with tidy desks cannot truly understand my wish to catalogue and deliberately acquire emotional artifacts. How do they organize their inner lives? Are they ever on exhibit?

Those of us who maintain these small collections of personal literary memorabilia, longing at times for clear work surfaces and tidy desks, are often also the chroniclers. Our artifacts are our inspiration – for letters, for reports, for speeches, for essays. Why else do we keep files of letters and notebooks of quotations? Who but us will leave the evidence of what daily life was like in our times? From pictographs in caves, to hieroglyphics in tombs, to the Dead Sea Scrolls, to illuminated manuscripts, to the Gutenberg Bible, to Penguin classics, to the Cloud, we have left our mark over the centuries. We have informed our descendants about the life of our times.

While historical figures of every period and nation have kept tidy desks and fashioned careful histories of the legacies they prefer, those of us whose only goal was to capture personal memories for private exhibits leave a very different legacy. Our recipes, letters and vestry reports left behind on untidy desks and in filing cabinets and on hard drives have lives of their own, our lives. We do not have time to organize everything into a well-shaped monument, or to order the possessions in our tombs. We will be found frozen in time, like the citizens of Pompeii, at the moment our lives stopped, still working on tidying our desks, still writing.

(Note: I’m sure you will notice that this essay is different from my usual posts. I wrote it for a writing course, where it drew such a positive response that I thought I would be brave enough to publish it here, on Christmas Day. This is the kind of writing I would love to have time for, although I don’t know what value it is. To anyone reading this, have the best holiday!)

Keeping Memories

We want our holiday memories to be good memories. If something bad happens, many people worry that this will affect the holiday every year into the future. What can you do about this? Isn’t there a way to have a choice about this?

What do you do with someone on what is likely to be their last Christmas? You do what you would always do. You visit them. You hug them. Do you remember that each time you hug them may be the last time they hug back.

The last time they hug back!

Hug them harder and think, “To hell with it!”

How many hugs have you given never knowing that this was the last? Too many!
Do not throw memory away on useless things.

Keep memory for the best moments. Keep memory for the hug after you see someone for the first time in a long time. Keep memory for your children’s best achievements: winning big races, graduations, for being a graceful loser, for every time they showed what a fine person they’ve become.

Keep memory for your first love. Not how they threw you over, but remember your passion, which they could never have handled.

Keep memory for the exasperating little habits of your mother, that you now miss so badly. Aren’t you happy now to remember them?

That we can, to some degree, control what we remember is one reason some of us keep journals and take photos, mementoes of events and situations we want to remember. This is one way we can ensure that we have good memories of people and situations, talismans to pull out for difficult days. For are there not also memories that are beyond our control? Why do some memories stay with us while others disappear? When do we have these memories? What bids them come?

Psychiatry has concerned itself over the years with the notion that there is a reason for the memories that stay with us. Have you not remembered something trivial and yet spent time contemplating what it could possibly mean, as if the meaning will be revelatory? Who has not wondered what a recurring memory or dream is trying to tell us?
What we are learning from Cognitive-Behavioural Therapy Research is how important it is to help patients find positive memories and to recall the positive emotional states associated with them. It is not our fault that negative memories are most influential in our lives, but it is important for us to recognize that these may not tell the whole story. It is the present and the future that hold the key to happiness.

What does this research mean for psychoanalysis, which once dominated psychiatric treatment? There would seem to be little research showing that the psychoanalytic focus on memory and the past can promote mental health. There is something of determinism in psychoanalysis – the idea that the past influences the future and that it’s difficult to break free of this past. But is there not something to be said for just letting go? For purposefully seeking positive memories, allowing them to be informative?

Hence the reason to keep positive memories: to hug deliberately and to remember the better part of today.

Do not throw memory away on useless things!

(Note: This is an image of Sigmund Freud’s couch from The Guardian.)

Anamnesis

What do you remember from your childhood? How far back do you remember? I believe that I have memories from the second house I lived in, close to downtown Pembroke, Ontario where I was born. In my memory, I am with my older cousin who is taking me to a Lumber Kings hockey game. I was just under 4 years old and I didn’t know what a hockey game was, although I thought it might be like checkers. I was so surprised and pleased by this special outing with my favourite cousin and I have always considered this to be my first memory – and one of my happiest memories.

So many of my patients cannot remember their lives before school started. In fact, many of them say they recall very little before age 10 and their favourite memories are often quite recent. Many of them have no good memories at all. Anamnesis refers to a patient’s account of their medical history but this account takes on particular significance in psychiatry where memories and their meaning in the life of a person can be difficult and can even affect how they recover emotionally from trauma they have experienced.

An anamnesis is the patient’s story. The word anamnesis is derived from two Greek words: “against” and “forgetting”. I like to think that a part of my work is to help people not forget the memories they have that are positive and healing.

I often work with youth and their families to develop memory books of good family times. I believe these can balance the impact of traumatic memories. Some of the most effective family therapy techniques involve asking families to build devices to protect their happiest memories. For example, if I ask each member of a family to bring in the family picture they like best and to speak about it, they may remember that the youth who is now surly and sullen was a little boy, eager to help and always kind. A picture of this boy with a little sister in their lap is the reminder. That picture, and its story, worked “against” “forgetting” that important fact.

The other memory problem that patients and their families often want to discuss concerns the “need” to “work through” traumatic memories. I have always been horrified by the belief so many have that you cannot recover from trauma until you have been forced to remember what your mind wants you desperately to forget. At these times, I think anamnesis can work against a patient, which is what we observe when someone’s traumatic memories “trigger” them. I have no difficulty listening to my patient’s traumatic memories, but I have a lot of difficulty with the view that they should be “encouraged” to have those memories if they’re not sure this is a good idea, and the research is beginning to show exactly that. Having said this, the research is also demonstrating that the stories that go with our memories may contact as much fiction as fact. In other words, the way we remember things may not be accurate. Why then, I ask, “work through” them?

I have been contemplating this problem of the meaning of the patient’s story, as they remember it, since I hear so much at this time of year about patients’ “best” and “worst” Christmas. I have observed that people can be healed by hearing and telling their own stories. There is research that supports this clinical observation and so I listen to all the stories people want me to hear even as I wonder about the value of the research, and hope that I’m helping.

I believe it helps because I remember the wonderful afternoon I believe I spent with my cousin, learning that hockey was not much like checkers. If the research is accurate, then the whole thing likely never happened. But, if you don’t mind, I’ll ignore this. This is my first memory of what it means to come from a large family – the kind that looks after you when you’re twelve and your dad dies. That’s my story and I’m sticking with it.

(Watching the Pembroke Lumber Kings)

How to Manage a Suicide Pact

Recently at a Montreal high school, 62 high school students made a suicide pact. As the story broke last week, the Montreal Gazette revealed that school officials had determined the three people who started the pact, who claimed that it was a prank. The article also quoted a school official as saying that “some of the students did not know what they were signing because only the first sheet indicated that it was a suicide pact”. No doubt school personnel were trying to allay the fears of the public, and more importantly, parents of students at College d’Anjou, a private high school in Montreal’s east end.

I learned about this situation when I was asked to comment and provide advice for Global News. I found the tone of school officials, as characterized by the Montreal Gazette, to be troubling. We know too much in 2017 not to be concerned whenever news of a suicide pact emerges, especially among youth between 15 and 24 years old. During these years, suicide is the second most common cause of death.

Some of the other facts that ought to have engendered more concern are the actual statistics about suicide and suicide attempts in Canada. The Canadian Mental Health Association has found that 34% of youth between the ages of 15 and 24 have contemplated suicide – one third. Also, the actual number of suicide attempts in this population in Canada is 8%. Both the rate of contemplation and the rate of attempts increases when there is a suicide pact. The acceptance implied in a suicide pact reduces a young person’s emotional barriers to suicide and so the risk increases.

What should happen when a school learns of a suicide pact? There are 3 direct steps that might help. The first step consists of education through assemblies. Bring all concerned together, in this case the entire student body along with their parents and other interested family members, e.g. siblings. Have an experienced resource person speak to this group about what to do to reassure themselves that their family member will be okay. This person can direct the assembly to resources for Mental Health First Aid as well as to local crisis and emergency services. There will be lots of questions about both the general subject of suicide and suicide pacts and about the specific situation. The resource person and school personnel should be prepared to address these. The school personnel must be prepared to address concerns openly, without judgment, and compassionately. This is not a time to be defensive. It is a time to make sure you have support moving forward should there be a need for further mental health assistance.

The second step must involve meetings with mental health professionals for each person involved in the pact. The best scenario is that one third of these youth were contemplating suicide and it is important to reach out and find help for these young people.

Finally, it is an important time to remind everyone of these three circumstances that indicate an increased risk of suicide in a young person:
1. Increased use of alcohol and drugs.
2. Giving away one’s belongings.
3. Signs and symptoms of depression or a history of depression.

Doing all of this is a good start to preventing suicide, but suicide and suicide attempts are symptoms of a serious medical illness. People die of serious illnesses. In some cases, such as this, these deaths can be prevented.

If anyone reading this has questions, please ask. The best way to prevent suicide is to talk about it openly and without judgment.

Black Box

What happens when memories are triggered when you least expect them? In my current life, practicing psychiatry, I usually think of triggering as something negative and difficult, but what happens when something positive and affirming is recalled?

This week, I was in Montreal on a cold November evening for the first time in thirty years. I walked around the Lower Campus of McGill University, again something I have not done for thirty years. Through the windows of buildings that I had known too well, I saw young people pouring over their work, as I had done. McLennan Library was bustling, a sign that there is less than one month before exams and papers are due. I shuddered with the memory of all that work, wondering in the moment how I had ever gotten everything done.

I was reminded of a long-forgotten schedule and I hastily turned up McTavish Street, heading from Sherbrooke Street toward Dr. Penfield Street, toward the Students Society of McGill University Building and the Players’ Theatre. Forty years ago, I spent more time with the Players’ Theatre than I did on any of the things I was supposed to be doing, like reading Harrison’s Textbook of Internal Medicine or reviewing anatomy for my surgical clerkship. The time I’d spent there had meant that I’d barely managed to pass anatomy, but, on the other hand, the time I’d spent there had helped me to survive four years of undergraduate medicine. I could never understand how medical studies could be so much more sterile and heartless than the English and Theatre from whence I’d come, but they were.

Players’ Theatre was founded in 1921, operated completely by undergraduate students at McGill, funded completely by ticket sales. I remember selling tickets to plays, although I don’t believe I ever sold one ticket to my medical school classmates. Theatre was my shameful secret and, even now, I feel I am confessing a weakness as I write this.

Buildings such as the Students Union Building are open at 7 p.m. and I walked in to the building and into the theatre. Players’ is a Black Box Theatre, a simple performance space with plain, black walls and sets are always minimal. It is a space where actors and audience can imagine freely what the scenes might be. As I looked at the space forty years later, the scenes I recall are vivid. I am experiencing flashbacks, I realize. This plain space, so ordinary and unremarkable, had kept my mind open as everything I had to remember in medical school threatened to close off and close down my imagination. The space had not saved my life, but it had certainly saved my mind.
I watched myself running from the space, after a performance, rushing to get back home to study such things as how the Loop of Henle works or the layers of the retina. How could I remember soliloquies, but not remember the layers of the retina?

I am sitting on the steps, and a young woman approaches me, “Can I help you?”

“Oh, no, I’m just remembering. I used to act here, when I was a student, forty years ago.”

“What do you do now?”

“I’m a doctor.”

The young woman stares at me. Slowly, she says, “Do you know that we’re doing Fables now? It seems odd, you being here tonight after forty years and being a doctor, like you’re coming full circle or something.” Fables is a play by Jackie Torrens with four characters, one of whom is a doctor – a traditional, male doctor, but wasn’t that the case forty years ago?

I stand to bid farewell to the young woman and to the space. For now as then, I must rush off. There is something I must do. I had forgotten this healing place, but I must not forget again. I am not sure I will be able to return in forty years to be reminded.

(A Typical Black Box Theatre)

Holiday Coverage

This is the second year that I have been Clinical Director of the Youth Program at my hospital and, like last year, I am covering for my colleagues on the working days between December 25, 2017 and January 2, 2018. There are three work days during this period and our various programs include approximately 500 patients. That is a lot of youth and families who may need support during this time of year that can be very difficult.

While I am the only psychiatrist in my program available during this period, a few allied health staff will also be working but we are already contemplating what services to offer. My goal is that those youth and families who need it will get support, but that those of us supporting will have balanced, even enjoyable, workdays in the spirit of the season.
What will we do? Let me tell you what we’re contemplating and, if anyone feels inclined, I would be grateful for any input or ideas.

We will begin by providing all our patients with lists of local resources for families, such as the crisis lines, as well as the opening hours of the walk-in program for youth mental health. We will also provide lists of things to do that are inexpensive or free, since diversion can often take one’s mind off difficult feelings. We will especially direct families toward outdoor activities. There’s nothing like a few hours freezing together on a skating rink to get mood-improving endorphins flowing.

We’ll also provide other lists: a list of movies that can help when people are anxious or depressed and lists of TV shows that families can watch together. For those who don’t like the idea of too much screen time, there are read-aloud book lists. A visit to the library to pick up books, movies and music is an inexpensive, warm outing.

But let’s think for a moment of those who must in this season, when the emphasis for so many is on joy and miracles, visit us at the hospital because there is no joy and a miracle would be just one reasonable day.

We are thinking of having a group, for anyone who needs it: for youth, parent, sibling, aunt, grandfather. It will be more psychoeducation than psychotherapy. We will remind everyone of three important self-help activities:

1. Rest.
2. Eat.
3. Do something fun every day.

I repeat these here because these are good for all of us to remember. These few days off are a perfect time to sleep in, go for long walks and have long conversations with people. We will remind those who need support that we are not the only ones they can talk to. I am certain that every youth in our program has someone who would love to have a conversation with them. We will remind them of that and help them remember who that might be.

I have always preferred to work Christmas than New Year’s – at Christmas, everyone works hard for the day to be positive, filled with good food and the best company. New Year’s is about resolutions and regrets and doing better, as if we all forget the message of the previous week.

I like to be part of the group of doctors and health care providers working hard for everyone’s holiday to be happy and healthy. It seems like a singularly good use of my time and it is possible to make a real difference for people just by reminding them to rest, to eat well and to have fun.

I come from a family that told the stories of Chanukah and of Christmas, that could make peace with two traditions, two traditions that had faith in miracles. I will spend the holiday reminding those youth and families who are having a bad time not to give up hope.

If you have ideas how I can be successful, let me know. I rely on others to tell me what I’m forgetting, and perhaps telling me will help you to look after yourselves. We all deserve that.

(Note: I took this photo after the snow on yesterday.)