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)

Life and Death Reporting – A Book Review

André Picard has been reporting on health and healthcare for The Globe for over thirty years. His book Matters of Life and Death: Public Health Issues in Canada is a collection of oeuvre from that period, focusing on some of the most important heath issues of that period and for Canada today. Apart from being a practicing psychiatrist, I did work for a time in health policy for the Canadian Medical Association and I haven’t quite shaken the habit. Mr. Picard’s book has become a reference for me and I am referring to it time and again when discussing or considering healthcare.

The book is organized into fourteen sections on what are arguably the most important topics in Canadian Healthcare. Picard cites fourteen areas of healthcare that deserve immediate attention because of their impact on Canadians’ health and our health care system. These are Medicare, Mental Health, Drugs, War on Drugs, Aging, End of Life, Children, Reproductive/Women’s Health, Disability/Inclusion, Indigenous Health, Cancer, Infectious Disease, Lifestyles, Social Determinants. Each topic has its own chapter and the book is very readable and understandable even if reading about health and healthcare is not easy for the reader. As someone who promotes health literacy to the sixteen year old adolescents in my practice, this is important. The short articles in each chapter are interesting and well-written. Members of my team and I used Sip on this: Like all drugs, alcohol isn’t Consequence free for a group about alcohol use in teens.

As I said before, this book has become a reference for me on Canadian Healthcare. I like to have good health policy information, to have the correct statistics and an impression of how others might be considering a health policy topic. Matters of Life and Death was accurate from these perspectives in those areas of health care where I have very good knowledge, which was always reassuring. Also, even when I don’t agree with his opinion, I can always see Mr. Picard’s point of view. This is the essence of good science journalism to me: that it stimulates dialogue and further consideration.

I feel that Matters of Life and Death is a book that every Canadian who wants to understand the problems our healthcare system should read, but I also think they would enjoy it. I will also say that the most valuable information provided was found in the Introduction. Mr. Picard compiles a list of the shortcomings of health reporting. He cites a list developed by Gary Schwitzer, a well-known American health journalist, and then develops the list further. That list is a lens against which one can evaluate journalism on healthcare, a good tool to have when you’re trying to decide whether an article is worth consideration.

(Note: I read the 2017 Douglas & McIntyre paperback edition of Matters of Life and Death: Public Health Issues in Canada.)

(My own photo)

Mental Health Measures Anyone Can Do

There’s something about the Samaritan’s #LittleThings campaign that really appeals to me. Every time I see or read their suggestions and material, I am reminded that the best public health measures are simple and straightforward. They are also easy to remember and often easy to manage, so I decided to offer three suggestions, taken from the #LittleThings campaign, everyone can use in a medical or mental health practice that have been proven to be helpful in improving mental health. These would also be useful to anyone struggling with a mental health problem, or their family members.

My first suggestion is to do hospitable things. In our offices and at the reception desks in our program, we leave out water and glasses, snacks and interesting reading material. We keep the space clean and tidy and welcoming. Research shows that people react positively to welcoming situations so positive greetings and just very simple but special items can really help. When I had a private office, we would put out handknit slippers in the winter. People really liked these, especially that my mother had knit them in all sizes for the office. To consider how this works, imagine yourself going to a doctor’s office, and what these are usually like. Then think how it would seem if there were something to drink, a kind voice to greet you, anything that helped you to feel valued and welcomed. I don’t think it’s surprising that the evidence supports that it is good for our mental health when first encounters are positive.

The next suggestion is to learn to listen well. There is a great blog, Just Keep Swimming, written by a person “who uses the mental health service in Ireland”. One of their blogs, The delicate art of listening, contains some good suggestions on how to listen well. There is much being made today of the benefits of health care providers listening to their patients, but all those benefits apply to our personal conversations as well. Again, it seems simplistic but another proven way that we can promote mental health is by listening.

The third suggestion is a little more complicated, because it would involve some expense for a practice or office, but its value psychologically is well established. It is to send personal greetings by regular mail. This is a good suggestion if a family member or friend is living with depression – send them a card or letter from time to time and it will help them to manage the negative feelings. In my practice, at the end of a person’s hospital stay, I will often have patients send themselves a postcard or card to remind them of some fact about themselves or some advice that is positive that they often forget. People in general don’t get real mail any longer and it can be encouraging to receive something personal when you least expect it in the mail.

So that’s it! I imagine some readers are thinking, “Well, that’s just more wellness nonsense. Who bothered to prove that scientifically?” Well, you can find that out in the #LittleThings material also. I have not put the case for wellness activities as a part of healthcare deliveries especially well and maybe I will work on that from a Canadian perspective, but Harry Burns puts it very well in this short piece in New Scientist. Harry Burns is a Professor of global public health at the University of Strathclyde and a former Chief Medical Officer of Scotland. So consider the advice of a public health expert in this and consider some of these suggestions.

Hunger For Justice

About once every month, I buy a patient or a patient and their family a meal. This is always embarrassing for them. Parents especially struggle when I insist that they must also pick something for themselves. I understand this. No one likes to admit that they’re struggling to feed their family. I did learn, however, that when I didn’t insist that parents eat themselves that food was often saved for other children at home. At the same time as I would feed people, I would call the food bank closest to their home to arrange for the family to pick up food on the way home. Another embarrassment for them, but I insist, telling the family that they can volunteer at the food bank once they are managing themselves.

As a doctor, I find it discouraging that there is so much food insecurity in a country like Canada. Food Secure Canada estimates that 4 million Canadians are food-insecure – 1.15 million of these Canadians are children. In northern and remote communities, the situation is even worse. It is estimated that 2/3 of indigenous children are food insecure. Given how unlikely it is that families are volunteering this information, I am confident that these numbers are low. I have met teenagers who are not even aware that they are not getting enough to eat. They are told that adolescents are “always hungry” and they believe that their own hunger is a normal state. I advise residents and medical students to find out in detail what their patients are eating so that they can truly assess whether their patients are getting enough to eat. Adolescents need a lot of nourishment, especially adolescent boys. We have known this since the time of Plato who said, “A boy is an appetite with a skin pulled over it”.

Food Secure Canada works to advance food security and food sovereignty through 3 goals: zero hunger; safe, healthy food; a sustainable food system. To help the youth that I see, I encourage schools to support breakfast and lunch programs. Snacks and meals are available in many of our Outpatient and Day programs. In my neighbourhood, the Parkdale Food Centre works with restaurants, schools and even the local theatre to grow food all year long and to help young people learn to cook. Community meals are a part of the social support network across Canada, often run by faith groups but also by food banks and restaurants and other agencies. Despite all these efforts, people still go hungry. The Ottawa Mission serves 1300 meals per day and food banks estimate that over 40,000 people in Ottawa are food insecure. Last year in Toronto, 136,000 children needed school lunches.

There are just over one hundred youth seen in our outpatient program at my hospital every week. These youth and their families are already managing at least one family member’s chronic health condition. Given how many of these are from marginalized groups, it’s likely that as many as 40% are not getting enough to eat, leading to even more health problems. We have not been able to figure out who most of them are. I don’t know if food banks and social agencies could manage to help everyone if we did.

The lesson from my experience is that every doctor in Canada, no matter where we practice, no matter how prosperous our community, needs to ask their patients if they are getting enough to eat. Once we have asked, we then need to accept that many, many people will not be truthful about this. They are too ashamed.

Our patients are hungry, and we must be hungry also…for justice.

(Note: This is a picture of one of the Parkdale Food Centre’s growing towers.)

More on Safe Injection Sites

The debate on safe, supervised injection sites is intensifying in Ottawa, with a lot of media interest. On Tuesday morning I was interviewed on CBC Ottawa Morning regarding this issue.

I was pleased with how fairly I was interviewed by Robyn Bresnahan. She really elicited all the concerns in this complicated issue. Here is the link:

http://www.cbc.ca/player/play/2686690858/

Thank you to everyone speaking up about this important issue. Please look back through the last few items and let us know what you think.

SoMe: You, Me and Health Care

Have you ever participated in an online event? If not, let me introduce you to these and consider briefly how such “virtual meetings” might improve the conversations we are all having about health care.

Last Wednesday, I participated in two online events – I can actually say that I participated in both events at the same time. One was an hour long tweet chat from 9-10 pm. This was the weekly @hcsmca tweet chat. You can find out more about this weekly event here along with a very detailed description of how you can join. This online event is held every Wednesday , usually from 1-2 pm Eastern Time. It is held from 9-10 pm Eastern Time the last Wednesday of every month. You can find out what the weekly topic is by following @hcsmca on twitter. The chat is for anyone interested in health care.

The second event I participated in was #BellLetsTalk Day. This event was inaugurated in 2010 as part of an effort to end the stigma surrounding psychiatric illness. Over $6 million was raised this year alone in a twenty-four hour online event. Bell pledged 5 cents for every post, tweet, retweet, text, etc. that contained #BellLetsTalk in the text. Throughout the day, whenever I had a minute, I would generate more retweets and add to conversations. I’ve talked about #BellLetsTalk before, however, so I’m not going to consider it further.

What interests me most about online communication is that it breaks down barriers, allowing me to participate in conversations from the comfort of my own home. I am the kind of person who goes to community meetings and learns so much that I wonder why I don’t go more often. However, I quickly realize that I often don’t feel like battling traffic or weather to get to meetings. Well, there is no need to worry about either at an online meeting. An online meeting is very accessible.

The topics for these meetings can be very timely. For example, the #hcsmca tweet chat last week considered whether health care professionals have the same rights of free speech on social media as other users. This is the summary of the conversation.

The chat considered two blogs, one of which was mine. The comments caused me to consider how I decide what to say and how I express my opinion.  I am as careful as I can be not to release another’s story. On this blog, I always state what permissions I have obtained and note whether the information is already in the public domain. I do try to present views or opinions that have a different angle that those that have already been publicly expressed, but my goal is to do this in such a way as to be heard. I do change my mind when convinced that I have erred or not had all the evidence. Some people seem to more freely express their opinions online than in person, as if it is easier to speak their mind when they do not have to look someone in the eye. This is one of the risks, blurting something out in a tweet.

Personally, I miss people’s reactions, verbal and nonverbal, when I am expressing an opinion. These are communications that I rely on when deciding whether what I am saying makes sense or not. In this respect, social media lets me down. What is not disappointing, however, is being able to discuss a clinical problem from the perspective of patient, care provider, family member and healthcare journalist. There are so many elements of a clinical issue that can be considered in an online forum because literally anyone can participate. Also, if I am reminded of an especially good article or website during an event, I can find it because I have all my own resources at my fingertips. I like that – how often have you wanted to answer someone right away with the research that proves your point?

There is so much potential for social media and the internet in healthcare that I cannot get my head around it. The #hcsmca chat on Wednesdays begins to consider some of that potential. I am finding that the views expressed are helping me to be more informed about healthcare and the internet.

With my new interest, I am reading articles I would never have looked at previously. For example, look at this month’s issue of Daedalus, the Journal of the American Academy of Arts and Sciences, which is entirely devoted to the internet.

Some of the concepts described are so innovative that I can barely understand them but they do convince me that online meetings promote a more thorough consideration of issues than some face-to face meetings. You should join us sometime at the #hcsmca chat and see what I mean.

2 Hospital Days

In the two weeks since I last communicated with you, I have had an unwanted but unique insight into one patient’s experience of the health care system. The patient was my husband. On December 28, he was admitted to the Civic site of the Ottawa Hospital, his respiratory infection having developed into lobar pneumonia.

I am not certain I could have convinced him to go to the Emergency Room for an assessment had the presentation not included left-sided chest pain – the one warning sign most men his age will not ignore. Fear of a heart attack in older men is more compelling than laboured breathing, sweating and shaking chills, nausea and vomiting and the respiratory tract infection that he had been experiencing. The assessment in the Emergency Room was straightforward and thorough but, in due course, my husband was admitted to hospital for intravenous antibiotics and fluids since dehydration had become a complicating factor.

Having been admitted to hospital just as the first snowstorm of the year hit, the course of Andrew’s treatment was uncomplicated and his symptoms resolved within one day. In fact, I had expected him to be discharged after twenty-four hours but the schedule of ward rounds was thrown off both by the holiday and by the weather.

When I visited him on the first day, while he was much improved, he was also clearly shaken by his experience of how unwell others around him were. He had been kept awake by patients shouting and screaming, their suffering so severe that my husband wondered how the nurses and other ward staff actually endured the stress of these situations, day after day and night after night. He marveled at their cheeriness with him and their professionalism and care for the woman in the next bed who was unresponsive to her caregivers’ ministrations.

The unit where he was cared for is one of the hospital’s Clinical Teaching Units in Internal Medicine. He was impressed on the one hand by the care he received but shocked by the crumbling infrastructure around him. Again, his thought was for how difficult this must be for the people who worked there every day.

My husband is a lawyer, an intelligent man with an eerie capacity for intuition. To cope with situations that are emotional, he seeks to understand them. What he observed were professionals who did not allow difficult working situations to interfere with the care they provided. Each time I visited him, he told me how much he admired me for the work that I did. It was clear that he had not completely realized the degree to which deteriorating health care equipment and decreased staffing are a factor in health professionals’ work lives. I suspect that no patient does realize this until they experience firsthand the degree to which our hospitals do not look like the facilities in General Hospital or Grey’s Anatomy.

What is perhaps more important from my perspective is that my own descriptions of the conditions and circumstances have not truly communicated the degree of concern that I have about how much health care support systems have deteriorated in the years that I have been practicing medicine. Staffing has been systematically decreased, equipment has not been replaced appropriately, buildings have been left to crumble and food and cleaning have been outsourced to the point that these do not meet the standards for nourishment and cleanliness that most health care professionals would want for themselves.

For the first day after he returned home, Andrew spoke to all those who enquired after his health about the state of the hospital and the stress the staff experienced at work. Several times, he was overcome with emotion when describing his experience. He had clearly been traumatized by the realization of what being in a hospital was like for a patient.

It has taken me fully a week to process my own thoughts about Andrew’s experience. I have always believed that the only reason Canada’s health care system continues to provide good care has to do with the people who provide that care. As funding decreases, they do the best they can to remain cheerful with patients and to overcome deteriorating conditions. In fact, we have gotten so good at doing this that it is possible that we are not expressing sufficiently well how urgent the need for change is. In my view, I have regularly spoken at home about my concerns about dwindling resources but it took an actual hospitalization for my husband to realize how dire the situation is.

I am hoping that my husband’s story will serve as a cautionary tale that it is only the health care professionals holding our system together. I was not at all surprised by the conditions he described, which is only another indication that I have learned to adapt. It is time for those of us devoted to health care to stop adapting to situations that traumatize the people we are caring for. They are clearly also traumatizing for us.

(Note: I dedicate this to the health care professionals at The Ottawa Hospital who cared for my husband – especially his doctors and nurses.)