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)

Get the Flu Shot – Promote World Peace

Tomorrow, nursing staff in the Youth Program at the Royal will offer the flu vaccine to inpatients. This is the kind of public health work that nurses often do, education and prevention, and they are very good at this work. But, inevitably, from time to time, they will have to present the science that vaccines work and I have pulled together my approach to flu vaccine advocacy.

I prefer the World Health Organization website information which includes an article that lists the proven benefits of vaccines, including all the scientific references. Let me present the abbreviated version I’m going to use if anyone asks me tomorrow why I think they should use vaccines.

I remind my patients (and anyone who’ll listen, really) that there are four different categories of vaccine-related benefits: diseases are controlled; the unvaccinated population is protected; related diseases, even cancer, can be prevented; and there are other societal benefits as well, such as economic growth, promoting equity and even peace. These benefits are all proven in studies and the WHO website lists those studies for the skeptical.

To present a compelling argument regarding disease control, I am going to keep handy the picture below of the statue erected at World Health Organization Headquarters when smallpox was eradicated. Smallpox was declared eradicated in 1979, almost forty years ago. This took an international effort and even countries that couldn’t get along for other reasons got along to eradicate small pox. They are now working to eradicate polio, with a timeline to complete this by 2018 – next year. This will be a historical event of great importance, again the result of a level of international cooperation that is now rare.

I am going to emphasize that vaccination against certain infections can prevent other diseases, including cancer. Prevention of chronic liver infection with the Hepatitis B vaccine can prevent liver cancer and even now, barely 10 years after the introduction of the HPV vaccine, scientists are measuring the decrease in incidence of cervical cancers caused by serotypes 16 and 18.

Finally, I am going to speak about all the societal benefits. I am going to begin by summarizing the savings. It is well-established that public health measures save $7 for every $1 spent, but vaccines are sometimes even more economical. Some studies are now available that show that $10 can be saved for every $1 spent fully vaccinating very young children.

As for equity, the burden of the diseases that vaccines can prevent is borne mostly by the disadvantaged. When this burden is lifted through vaccination, these groups are more likely to flourish.

As for peace, the United Nations Children’s Emergency Fund (UNICEF) has medicated at least 7 cease fires during civil conflict that were related to vaccines. Even people in conflict can resolve some differences so that disease can be prevented.
Being vaccinated is one of the few things a person can do for the greater good and know that they are being effective.

I hope that my young patients will be convinced with this science of the value of vaccines, but I will still thank them just for listening to my public health service announcement. I have also made cookies that look like viruses (sort of) for the vaccination celebration. Vaccines deserve celebrating, I’ll tell them.

Get the flu shot. Have a cookie. Promote peace.

Bleak Midwinter

The holiday season has officially started. I have begun to make a list of the families in my practice that should receive grocery vouchers so that they can afford food for the holidays. I also make a list for the teenagers who are living on their own. I confirm addresses and watch young people’s faces closely so that I can discern whether they are, in fact, housed. I ask them if their housing is safe, looking them right in the eye. I have a list of numbers on the corner of my desk for families or youth to call if they need housing. I have lists of where free holiday dinners are provided and where one can sign up to receive gifts. I am not trained for any of this. In fact, few doctors are trained for this work, but we all do it.  The hardest part of this work is finding a balance between the fear I have about how precarious my patients’ living situations can be and the realization that I have a responsibility to make that situation more secure.

I know there are many who will say that this is not a doctor’s job, but I cannot escape the knowledge that I have that says otherwise. Every doctor I know works for the best for their patients even when the best has nothing to do with pathology, physiology or medicines. Every doctor I know asks their patients questions about their income and work and family life.

The sharp contrast between the glittery mall displays and the realities of many lives is especially evident at this time of year.  While so many are focused on what they want the holiday to be, others are thinking of what they need so that the holiday is bearable. The impact of this contrast on mental health is significant.

At a time of year when family is glorified, the difficulties in one’s own family become highlighted. The support of family members is known to be a factor in good health, but how many people do you know who dread the “family” events that come with the holidays? How many of those events end much differently than sitcoms would have us think? Many of the youth I see live in care. Some will be preparing for a visit with family of one kind or another. Some will have days or even a week with their family. Helping youth stay realistic about these visits and the holidays is very difficult for those of us who care for these youth.

I am always most concerned about the youth who do not have a family to visit. Most people around them will be planning a visit and excitedly buying and wrapping gifts and planning travel. The youth without a family will be sharing their Christmas lists with a youth worker or social worker. You will receive gifts, often thoughtful gifts of things you want, but you will not have what you really want which is love, true affection from someone who has known you all your life and is happy for just being able to hang out with you. As a psychiatrist, I could point out the link between “hanging out” and endorphins but I think this just serves to distance us from the feelings. If you can understand what a young person with no family is feeling, you know that this feeling is not good for someone’s mental health.

As a physician, I always take some time off in November or early December to prepare emotionally for the holiday season, whose starkness is so evident in psychiatry. Then I come back to work ready to spend the next month social determinants of health.

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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.

More on Safe Injection Sites

Every day I see patients who need a safe injection site in Ottawa. This would not only help ensure their physical health but the health promotion geared to help them stop misusing injectable drugs would be more available to them.

It is important for this issue to be debated widely so I was pleased that my letter to the Editor on this subject was the lead letter in Saturday’s edition. Have a look at it and at the other letters as well. This is the link.

Also, if you are wondering how Safe Injection Sites actually function, TVO produced this great documentary on the subject.

People do ask me how people as young as my patients, who are mostly between 16 and 18 years old get hooked on injectable drugs. Often these people are worried that Safe Injection Sites actually promote more drug-related crime. This is actually the concern of Ottawa’s Police Chief.

It’s not difficult, unfortunately, for children and youth to get hooked on drugs because they have access to them at school. I do not know whether Ottawa is unique but I ask most of the youth that I see – and not just the ones who are have a dependency or abuse disorder – where they got access to the drugs they tried and all of them say that they could get them at school. Even elementary school. It’s not unusual for children to try drugs when they are in Grade 7 or 8 – 12 or 13 years old. As a society, we need to protect our children more effectively. Better mental health prevention is needed in schools.

Thank you to everyone who is working to improve youth mental help and especially to everyone who has emailed me or communicated about my last blog. I hope this additional material is helpful and look forward to your comments.

Public Health Hero

I first met Dr. Isra Levy sometime around 2000 when he and I crossed paths at the Academy of Medicine Ottawa but I really got to know him from 2002-2004 when he and I both worked at the Canadian Medical Association. At the time, he was the Director of CMA’s Office for Public Health and I was the Director of the Office for Women in Medicine.

Public Health is an interesting specialty in Medicine. One could argue that it makes more difference than any other branch of medicine since the measures it promotes – like clean water or vaccines – can have the biggest impact on personal health and health care. Public health concerns population health and reaches into all areas of our lives. I am privileged to have been a delegate to the World Health Assembly in Geneva on numerous occasions and have material on vaccines, road safety, maternal pre-natal screening, domestic violence – issues that exemplify the reach of these specialized physicians.

I have learned more about public health from Dr. Levy than I ever learned in medical school. When I worked with him daily, he made you think about the impact any measure could have on public and population health. Someone with such an inspiring breadth of knowledge can be intimidating but Dr. Levy has such a wicked sense of humour that I always felt forgiven for my mistakes.

All this preamble is meant to let the reader know that I feel I know Dr. Levy quite well so please believe me when I say that he is highly principled and ethical. When he tells us, as the City of Ottawa’s Medical Officer of Health, that we should fund safe injection sites then we should listen to him. I learned years ago not to explain issues that Dr. Levy explained best so here is his public letter regarding safe injection sites and their value.

Dr. Levy’s letter makes it clear that Safe Injection Sites are an important, evidence-based pillar in the treatment of Substance Misuse. As a Psychiatrist involved daily in the treatment of youth with Substance Abuse Disorder, I want to know that they can access Safe Injection Sites when they need them. Otherwise, I am going to have to manage the risks of not having this important public health resource.

The problem is that Dr. Levy has two important City of Ottawa partners who disagree with him: the Mayor and the Chief of Police. This is formidable opposition and so, for all it’s worth, I’ve decided to use this small article to urge you to support Dr. Levy’s evidence-based approach. It takes a great deal of moral courage for Dr. Levy to oppose the views of the Mayor and the Police Chief, but he is doing the only thing a doctor in his position could do.

The opinion of Ottawa’s Medical Officer of Health that the city needs Safe Injection Sites is good public health policy. As a physician in the community, I support this. As a physician who works daily with addicted youth, my patients require this measure. As a community, this will protect us and protect our families.

isra

(Note: The attached picture of Dr. Levy is in the public domain.)

 

The Government Hand That Rocks The Cradle

Today I read two stories about government assistance for babies and the families that care for them. After reading these two reports, I found myself thinking that Canada does not welcome its newest citizens as well as it could. I will start with the story of how Finland welcomes babies and it was posted on facebook by Dr. Judy Patterson. http://www.bbc.com/news/magazine-22751415

As a mother myself, I was intrigued by the account of how all expectant mothers in in Finland receive a box containing the necessities for their new daughter or son, a tangible expression of the country’s concern for that child and, with some items like a picture book, its hope for that child’s success. Notwithstanding that Finland also offers universal health care and a full suite of infant screening to ensure the ongoing health of its newest citizens, the BBC story detailed some very personal accounts of how mothers of several generations reacted to this social service.

Apart from providing everything from clothing to a makeshift bed, the Finnish baby box also provided an opportunity for the Finnish government to impart to a family some of the values of their culture. For example, the items are in unisex colours and patterns promoting and encouraging gender equality.

The second story is from Ottawa, where last night, Ottawa Public Health tabled a budget that proposed cutting services for babies and their families: http://ottawacitizen.com/news/local-news/programs-for-newborns-at-risk-as-ottawa-public-health-tables-2015-budget

Because of a provincial freeze in funding to municipal public health programs in Ontario, Ottawa Public Health will no longer be able to check in with new parents or provide antenatal courses. Such programming is the backbone of preventative care for marginalized families. While Dr. Isra Levy, Ottawa’s Chief Medical Officer of Health, says the check-in calls will continue for some at-risk families, many families will no longer have access to services. To offset the need to adjust because of provincial budget cuts, more information will be available to families online. It will give new Mums and Dads something to do on sleepless nights with a colicky baby.

Think about these contrasting stories and ask yourself which government sounds more caring to you: the one that welcomes new citizens and their families with a gift of warm clothes and bedding and even a book, or the one that sends a worried parent to the internet?