Opioids and Social Capital

Over the weekend, I read the first article about the opioid crisis that made any sense to me. It was published in Scientific American last week and explained why so many of the strategies that we are using to combat the rising rates of opioid overdose have been ineffective in curbing the rate of overdose to any great degree.

The article summarizes the research that suggests that the best ways to address the abuse and dependence on opioids is to help communities strengthen the social ties between people. The author opines that the emotional reasons that we become dependent on any substance are factors that communities should seek to address in to reduce the morbidity and mortality related to opioids.

In one study published in the Journal of Health Economics, researchers looked at the impact of macroeconomic changes on opioid use in specific counties and states in the United States. For the region studied, researchers found that, when the county unemployment rate rose 1%, the opioid death rate per 100,000 rose by 3.6% and the opioid overdose Emergency Department visit rate rose by 7%. These statistics held throughout the state.

The article summarizes the science related to the body’s naturally occurring opioids – endorphins and enkephalins – these help us to moderate both physical and emotional pain. The science is outlined concisely and briefly and reminds the reader of those factors which increase the levels of these naturally occurring opioids. It also reminds us how this hormonal system insulates us from emotional pain in our lives.
I have never prescribed opioid medication myself, and most of the doctors I know are similar in practice to me so I have been bewildered about who all the doctors prescribing them could possibly be. I’ve seen the numbers, however, and I certainly know of physicians who have gotten into difficulties because of the way they prescribe opioids. I understand that physician regulatory bodies have sought to address the increasing rate of opioid abuse and overdose by offering courses on prescribing these medications.

To address this dangerously increasing use of opioids, communities have been distributing naloxone kits, setting up safe injection sites and running health prevention campaigns. I support these measures as urgent action must be taken in the moment to do what we can to prevent harm to those already at risk because of opioid use.
Having said this, it’s time to think about what can be done to address those social capital deficits. The OECD defines social capital as “networks together with shared norms, values and understandings that facilitate co-operation within or among groups”. These networks include such networks as family, friends, groups we belong to, or organizations that support us. According to the research, the loss of social capital is linked to increasing opioid use and all its attendant risks.

I’ve been thinking of social capital lately as I’ve worked to find supports in their communities for youth in my practice, supports such as groups where families might learn to cook or spend time with other families. As I did this research, I realized that some Ottawa communities are better at this work than others. It makes sense from this that communities might consider supporting community development as well as safe injection sites and naloxone kits.

Many reading this will believe that this is all about the social determinants of health but this is a reflection on the need for all of us to consider how we personally build communities. Do we go to groups? Do we initiate support activities? Do we go to community events? All things considered, cities can support communities but they can’t provide them the way they can buy naloxone kits or new services. They can’t make your neighbours neighbourly. That takes individual people getting out of their chairs, turning off the TV or their devices, and talking to people or working with people. While it does build a community to have skype meetings or online chats, this research is telling us that, if we truly want to have communities, then we must have some that we can walk to when we’re caught in a snowstorm or hurricane, or the power goes out. Perhaps if we volunteered at the food bank, it wouldn’t be so hard to go there for food, or even just company, when the need arose. Having community meals or parties or street events, bringing disparate parts of communities together, can help you find out what services you can have or help in your neighbourhood.

Last weekend, the Wellington West Community held an event on Wellington Street. As I walked along running my errands, I stopped off at a few services. I learned that one agency, Ottawa West Community Support, has a range of services to help seniors continue to live in their own homes. They told me that volunteering with them has helped many older people make the transition to using their services. That is social capital. I learned that the library helps anyone learn how to navigate the internet safely, from kids to seniors to newcomers. The library has an English Conversation Group. These are examples of building social capital.

This research and consideration has me thinking about how I could invest in social capital in my hospital practice and so I have been thinking about the kinds of groups that could most help youth in my community. I have a few ideas but would be interested in others’ ideas also. Please tell me. It seems a long way from the opioid crisis to me, but the research suggests that I am wrong. How do you build social capital? How do you think we could help?

(This photo has been in multiple places on the internet. I found it in Lawrence Wall’s twitter feed.)

Normal and Bored

There are six million young Canadians starting school this week. From busy, excited little kindergartners to oh, so bored almost adults in their finally final year, yellow buses and slower streets will signal the end of summer as nothing else does.
At the psychiatric hospital where I work, we have four classrooms, all part of the M. F. McHugh Education Centre, and the young people who are receiving treatment for their mental health conditions will continue to have access to education, even though they are not all well enough to benefit from that educational experience as much as we would like or hope.
As a clinician, one of the elements I value most about the McHugh classrooms is that they are a constant reminder to my young patients that there is a normal life waiting for them once they are feeling well. The very presence of these classrooms and their teachers is a reminder that everyone working with these patients has every intention of helping them get back into an academic life, a normal life.
Whatever age you are, becoming mentally ill turns your life upside down as no other life circumstance can. Often you cannot manage the very basics of getting up in the morning, or washing your face, or putting breakfast into your mouth. The idea that, on top of this, you’re expected to read Hamlet or learn about cell structure or get from classroom to classroom can be overwhelming. Imagine a classroom that supports you to manage exactly those studies while, fifty yards away, in another part of the same building, on an inpatient psychiatry unit, you are learning to cope with the voices telling you to kill yourself. It’s a lot to put together.
For a young person who is struggling with mental illness, or other difficulties, school can often be the most stabilizing influence in their life. If your dad left home on Tuesday, on Wednesday your class will still be reading Hamlet. If your grandmother passes away on Friday, and you saw your grandfather crying for the first time in your life, it really can help that cell structure does not shift in one week. If, all of a sudden, your mind is just not making sense, it helps to have a classroom where the teacher knows that this has not always been the case and that you will not feel this way forever. I think it especially helps to have a person who can bridge you back to the world where Hamlet and cell structure are important, and you can be a normal person again.When I was younger, I had wanted to be a teacher. The normality of life is one of the things I most miss about my life as a doctor. Like every physician, even when I focus on the person with me, I am often still focused on how well they are. Can they concentrate? Are they enjoying soccer once again? Is their mother back to nagging them about their room being a mess?
When you see a psychiatrist, and you’re sixteen years old, you know you don’t have a normal life. But, if every weekday morning you can sit in Mrs. Scott’s English class, listen to Mary Jo Jones be Ophelia and Sam Smith try to be Polonius, you can feel as though your life is as blessedly normal as everyone else’s. You can go back to being bored and everyone who knows you will think it’s a good thing to be normal and bored.

(Note: As a new school year starts, I will be hoping for the best year for students and teachers and especially for those students and teachers in the McHugh classrooms around Ottawa.)

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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World Suicide Prevention Day 2016

Today from 12:00 to 1:00 I will participate in the World Suicide Prevention Day Facebook Know What to Do Event. The event will be hosted on the Facebook page of the Children’s Hospital of Eastern Ontario (CHEO).  As well as answering participants’ questions, I have a short presentation to make on talking to your child about suicide.

When I considered what to say, I realized that the most important thing for a parent to remember when they have a suicidal child is: Suicide attempts and suicidal thoughts are symptoms of serious illnesses. They are caused by many different factors. Talking about suicide with your child cannot give your child the idea to attempt suicide and so parents should never worry about raising the issue. This is important for parents, and, in fact, for all of us to remember since stigma and blaming oneself are still more implicated in suicide that the fact that it is the outcome of a serious illness.

Because suicidal thoughts and suicide attempts are symptoms of an illness, I encourage parents, friends and others to ask youth about suicide when they are worried that a person may be suffering from ideas of taking their own life. Indicate your concern and your wish to help. A young person contemplating suicide needs to understand that you care about them, that you love them and that you’re going to do whatever they need you to do to get them help.

I advise parents to ask a young person how they can help. Offer to do whatever the young person needs and be prepared to follow through. If a young person is reluctant to talk to you, find someone they will talk to.

It is important for us not to judge suicidal thinking – it is the symptom of an illness. Ask over and over what you can do to help. Remember that statements such as, “You have so much to live for” or “Think how this will affect your family” are not necessarily helpful to a person with the despair that is another symptom of depression. Suicide and suicidal thoughts are not wrong – they are the symptom of an illness.

There is no perfect way to ask about suicidal thoughts. Just say, “I’m worried about you and I need to ask whether you are having thoughts of suicide.” Say, “I’m sorry if this upsets you but I want to help.”

As I write this, I am reminded of the many young people I have cared for who suffered with mental illness and suicidal thoughts for many months and even years before treatment began to be effective. I see their troubled faces first and then their smiling faces once they were feeling better. I work with a great team of social workers, psychologists, other psychiatrists, nurses, teachers, child and youth workers, recreation therapists, occupational therapists and experienced managers and office staff. We have teams at The Royal, at CHEO and at Youth Services Bureau. We all work together to provide the treatment that is needed for serious mental illnesses and to prevent suicide.

I want to end where I began: Suicidal thoughts and suicide attempts are symptoms of a serious illness. Children and youth do take their own lives and that is a tragedy. My thoughts are with those who have lost a loved one to suicide. My thoughts are with those who are suffering because of mental illness. On World Suicide Prevention Day, this is the message: “Let’s never give up. We can prevent suicide.”

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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.

Physician Activism: Put Your Money Where Your Mouth Is

This is Mental Illness Awareness Week 2015 and I want to talk about my physician heroes for mental health. The doctor heroes of my life and work this week are my colleagues at The Royal, the tertiary care psychiatric hospital in Ottawa that serves Eastern Ontario.

In this especially difficult time, when doctors are facing cuts to patient care and hospital doctors are coping with cuts to hospital funding as well as their own, the 70 doctors at my hospital are donating $1 million to the Foundation for Mental Health. The decision was made at our Associates’ meeting and received overwhelming support.

The donation will support care, education and research at the hospital. It is an extension of the clinical care, research and community action that is typical at The Royal. My colleagues care for patients from all walks of life, from youth to seniors with a dedication that is inspiring. We provide care in the hospital, shelters, community settings like Carlingwood Shopping Centre, group homes and prisons. The research undertaken in the Royal’s Institute for Mental Health Research is world-renowned. Our programing is innovative – we’ve even created an App to help young people cope with stress. My own small contribution to this innovation has taken the form of tweet chats.

My unusual schedule means that I often arrive early at the hospital or leave late. Regardless of the hour, I am rarely the only doctor in the building. I am proud to be a part of this group of physicians but I am also humbled by the talent and generosity around me.

People with mental illness have suffered both because of their illnesses and because of the stigma that has plagued these conditions. The doctors who treat these illnesses have also been stigmatized at times. Do you not know at least one psychiatrist joke? My colleagues know that stigma is not defeated with therapies and medication. Putting your money where your mouth is shows your stake in a cause and 100% of the doctors at my hospital will participate in this donation. I am told that this is unprecedented – no other hospital foundation in Ontario has 100% of its hospital’s physicians contributing.

If you are looking for doctors #OnCall4ON, here are 70 you can mention. If you are looking for champions during Mental Illness Awareness Week, look no further.

(Note: The attached photo is used with the permission of The Royal. The Doctors in the picture are, from left to right, Dr. Vinay Lodha, Dr. Michele Mathias, Dr. Alain Labelle, Dr. Ameneh Mirzaei and Dr. Pierre Blier.)IMG_9345

Physician Activism – Patients with Cardiac Conditions Affected

As an Ontario Medical Association Board Director, I am receiving many letters from physicians concerned about the impact the government’s cuts to physician services could have on patient care. I want to share this letter with you since it underlines the degree to which communities could be affected.

 

I have known Dr. Niznick, an Ottawa cardiologist, for many years. Many patients have relied on his clinic for their care. The government’s unilateral actions are putting that care at risk. He wrote to Dr. Kapur (OMA District 8 Board Director)and me with his concerns. Dr. Niznick has reviewed this article, including my comments and agreed that it can be published. I am posting it because it’s very important that the public realizes that all physician services will be affected by these cuts.

Here is his letter:

Hello Atul and Gail,

 

These are difficult and frustrating times. I appreciate the work you have done on our behalf. I am concerned about the incremental cut backs and the reduction in non-invasive cardiac fees.

 

My larger concern is the imposed deadline for accreditation of all echocardiography labs in the province by April 1, 2016. Whereas I have no doubt that our lab will be accredited and we have made application for that, the process is been exceedingly slow. There’s no possible way all remaining labs can be accredited in the proposed timeline.

 

The government has stated that any unaccredited labs will not be paid technical fees as of April 1, 2016. When this happens we will have to shut down our laboratory, reduce office nursing, technical and clerical office staff and possibly could force the closure the Ottawa Cardiovascular Centre.

 

Currently we have a population of 250,000 registered patients with about 40,000 active patients and about 100,000 patient interactions per year. The closure of the OCC would have a huge impact on the delivery of cardiology services in Ottawa. Neither the Ottawa Heart Institute nor The Ottawa Hospital could absorb our volume. Furthermore our practice subsidizes five cardiac nurses to provide telephone patient monitoring for a large variety of conditions. This monitoring often prevents unnecessary visits to the emergency department and proactively deals with issues such as worsening heart failure, atrial fibrillation, anticoagulation issues, progression of angina etc.

 

The bottom line is that these cutbacks are not as much a matter of money they are a matter of compromising our ability to properly care for our patients. The high-quality model that we have developed and subsidize with our technical and professional revenues will not be sustainable.

 

Please convey my sentiments to OMA Council.

 

Regards

 

Joel Niznick MD FRCPC

 

My thanks to Dr. Niznick for allowing me to publish this.