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.)

A Public Health Campaign for Legal Marijuana

When I first reviewed the Government of Ontario’s approach to legal marijuana, I was disappointed. I was hoping for an approach with a strong foundation in public health. I feel strongly about this and wrote about my concerns for the Ottawa Citizen.

As I read the views of other health stakeholders in legal marijuana, I could not help but notice that many of these felt that the government had addressed many of their concerns. Both Ontario Public Health and the Canadian Medical Association reported being satisfied with a legal age of 19 for marijuana, even though both had advocated for a higher age. The article I read said these organizations described the government’s approach as “pragmatic”. Why am I not satisfied?

This pragmatic approach focuses on regulations and where marijuana will be sold and the public health relies on regulation to manage the age of use. However, as all clinicians working in youth mental health and addiction, I know that the key to changes in behavior and attitude lie in education, specifically public education through health communication campaigns. In mental health, we are very familiar with how successful these campaigns can be. In the past ten years, vigorous health communication campaigns have  been able to neutralize the stigma that existed for centuries against mental illness and persons with a mental illness. I had hoped that, right from the beginning, the Health Minister would have pledged the funding for a sophisticated health communication campaign to ensure that all citizens understood the health risks of marijuana, especially youth for whom the impact on the developing brain can be significant. There was the promise that such a campaign would be developed, but no firm details were provided as to what steps have been taken to implement the campaign.

The campaign I wanted would include persuasive communications informed by social marketing strategies, with messaging designed for different target groups. The public health messages must be accurate, interesting and stimulating so that different communications might be needed for different groups and especially different age groups. I know that the Ministry of Health and Long Term Care can manage this level of sophistication. In fact, I even found a presentation entitled Developing health communication campaigns on the Public Health Ontario website.

The campaign I wanted would start now so that awareness of the risks of cannabis use and information about safe practices for using legal marijuana would be known by the time legalization comes into effect  in July 2018.

The campaign I wanted for youth would reflect the reality that Canadian young people are already the highest users of marijuana in Canada by age group. It would recognize that rules and regulations cannot be the only tools we use to prevent marijuana overuse and addiction.

Another public health element that I was seeking was the commitment of support for further research to evaluate the impact of legal marijuana. This will help us to understand how the Government’s approach might be improved in the future. It will reassure the public, including mental health professionals, that the Government is prepared to be prudent in ensuring that legal marijuana is introduced safely.

Finally, with the growing demand for mental health services, another element that I had hoped to see was a commitment to improved funding for services for addiction. While I do not believe that the legalization of marijuana will necessarily lead to higher rates of marijuana addiction, we know that the province’s coffers will benefit from increased tax revenues. Many groups were hoping for a commitment to improved services, services that are already much needed.

The legalization of marijuana is an opportunity for the Government of Ontario to demonstrate understanding that addiction is a mental health problem and that those people with an addiction should be assisted and not shunned. The young people that I see with marijuana addiction have higher rates of many psychiatric symptoms including psychosis and suicidal ideation and attempt. Many of the young people I see who are now in recovery would provide great advice on how the public health approach to legal marijuana could engage youth in its safe introduction. I hope the Government will seek the advice of those most at risk – people under 25.

Seria Una Cruz Verde?

I am watching the news from the Venezuelan election and wondering what I would do if I were a doctor in Venezuela today. The election is the most recent assault on the people of Venezuela by their President, Nicolas Maduro. By the end of the day, or within a few more days, he will become the dictator of Venezuela. The making of a dictator is the undoing of security in a country and many young Venezuelans have seen their country go from being the richest country in South America in the 1980’s to having an 86% poverty rate in 2017.
Since April, over 100 young people have died in protests in Venezuela. That total increased by 19 this weekend as protests over the election intensified. Venezuela’s neighbours, Brazil and Colombia are bracing for a refugee crisis. The country is experiencing a food security crisis and medicines are not at all available.
The scale of the humanitarian crisis was confirmed by Dr. Douglas Leon Natera, President of the Medical Federation of Venezuela. Natera is reaching out to colleagues in the region. This is a communication to Dr. Maite Sevillano, Vice President of the South American Region of Medical Women’s International Association:
“To the friends: The health sector being headed by the doctors is only attending emergencies, trying to continue to give priority to children, pregnant women and the elderly. These resolutions are being followed by 96% of doctors in public services and 85% in private.” (Personal Communication to dra Sevillano)
Venezuelan physicians are especially concerned about the impact on children, who have been most affected by the food insecurity. Also, youth have been the majority killed in protests against the Maduro regime, according to Dr. Natera.
In Venezuela, however, some of the heroes are also young. Medical students and recent graduates of the Central University of Venezuela have banded together as volunteers to provide first aid and whatever care they can to those injured in protests, on both sides. However, despite the group’s impartiality, government forces usually see them as part of the protest. As they help, some have been injured and one of the volunteers was killed. To identify themselves, the volunteers wear white helmets with a green medical cross and carry white flags bearing the same green cross. Cruz Verde (Green Cross) is what they are called and those injured in protests call out for them, and pray for them.
As most of the volunteers are in their twenties, they were born when their country was still wealthy. They have witnessed its disintegration. They are studying – and learning – the basics of public health, emergency medicine and the impact on health of a humanitarian crisis in the most unfortunate way. Their older colleagues, led by Dr. Natera, are also working to provide basic medical care to starving and desperate Venezuelans. When I read about their work and watch youtube videos of their working conditions, my own first world medical concerns dissolve into this philosophical question:
“Seria una Cruz Verde?”

(Photo credit: Christian Science Monitor)

#endpolio

There is nothing in medicine more elegant than a public health strategy, especially one that is well-planned and conducted efficiently. One of the best examples of such a strategy can be found in the Global Polio Eradication Strategy. The hope is that such a strategy will do for the world what a similar strategy did for Canada.
In 1953, polio peaked in Canada and, in a one year period, there were 9,000 new cases and approximately 500 deaths. The Salk vaccine was introduced in 1955 and the Sabin oral vaccine in 1962 and within 20 years of the 1953 peak, polio was under control in Canada. In 1994, Canada was declared “polio free”. In its peak years, the disease was so widespread that everyone knew a child who had developed limb paralysis because of polio. Of those who developed paralysis, 5-10% could develop paralysis of the respiratory muscles which could result in their death. It was for these people that the iron lung was developed.
Polio was a major worry for Canadian parents in the 1950’s. For many children, polio would cause fever, fatigue, vomiting, neck stiffness, headache and limb pain. I had two aunts who were pediatric nurses and I remember them speaking about the helplessness they felt nursing a child who had seemed to have a mild illness and then suddenly began to develop paralysis. My aunts have spoken about how much parents would dread whenever their child developed a fever.
When the Global Polio Eradication Strategy was initiated in 1988, there were still 350,000 cases of polio worldwide. The strategy was launched in response to a Resolution passed at the World Health Assembly. Within 20 years, thanks to 3 million volunteers worldwide, there has been so much progress toward eradicating polio that the World Health Organization believes it might be possible to eradicate polio by 2018.
The last bastion for polio is in three countries: Nigeria, Afghanistan and Pakistan. The challenges that perpetuate polio in these countries include insecurity, weak health systems and poor sanitation. It is possible for polio to migrate from these countries to other countries whose health systems are weakened by the same factors. For example, cases of polio are now being tracked in Syria.
The public health professionals and advocates involved in the efforts to eradicate polio are determined and diligent, and they will succeed. From the offices of the World Health Organization in Geneva to the grassroots volunteers around the world, there is a hopefulness in their websites and statements that is undeniable. What must be done to achieve their goal is simple: every child must be vaccinated against polio. It takes a lot of work to ensure that this is happening but many countries, and not just countries as rich as Canada, are managing this.
It is easy to understand why this can be managed. Anyone who has witnessed the suffering of a child with polio will want to prevent it. These witnesses will work to ensure that every child can be vaccinated. It is simple and elegant. You can watch the progress on social media by watching #endpolio. You can watch public health at work. You can watch the end of polio.
(Credit: This image of an iron lung is taken from the website of the Canadian Public Health Agency.)

My Predictable Clinical Life

In the past week, I have started to work on an inpatient psychiatry unit for youth. It is not easy being a psychiatrist for an inpatient program, but it is interesting and more predictable than outpatient psychiatry. In an outpatient program, emergencies arrive with little notice, often disrupting one’s schedule on days when there is no room for disruption. On an inpatient unit, the emergencies are right there in front of you all the time. This is predictable unpredictability and I find this more manageable than the frenzied calls that can disrupt an entire afternoon’s clinic.

For the past week, I have arrived on the unit to calls of, “Can I speak with you now?” or “What time are you meeting with me? I have stuff to do.” With a much smaller overall caseload than outpatient psychiatry, and patients who need to be seen daily, there is an opportunity to get to know the youth I am working with so well that their needs can be more thoroughly addressed.

The most common reason for psychiatric hospitalization for youth is to stabilize acute symptoms of psychiatric illnesses but case formulation and diagnosis and treatment plan development are becoming even more critical in youth psychiatric care. The reasons for this are embedded in the shortage of Child Psychiatrists and of youth mental health resources in general. Outpatient child psychiatry programs everywhere are stretched to the limit, to the point where the World Health Organization found that many mental health needs of youth around the world were not being addressed directly but rather through programs addressing other concerns. For example, street-involved youth often get more mental health support through housing agencies than from mental health agencies or hospital or clinic mental health programs.

Inpatient psychiatry programs and their function and purpose are not always well-understood, mostly because evidence often supports community treatment for some patients who would prefer hospitalization and hospitalization for patients who find the restrictions of psychiatric units too difficult to tolerate. This concept was summarized best by a patient I saw many years who asked me, “Dr. Beck, how come the people who want to stay in hospital can’t but the people who want to leave aren’t allowed?” When I responded, “I don’t really have a good answer for that question,” I was met with, “You don’t have any good answers.” I wish I thought that wasn’t true.

The WHO report emphasizes the need for greater collaboration between inpatient programs and the community. The social advocate in me loves the idea of working with schools, shelters, food banks and public health to develop the partnerships that will improve collaboration. The best outcomes for the clinical conditions where psychiatric hospitalization is indicated can be predicted based on social conditions. This means that those of us in who work in youth mental health must work with community partners if we are to have any success at all.

It also means that I will be diagnosing and treating conditions that go well beyond mental health into personal and social well-being. Hence, on my first day back, it was predictable that I would find myself gowned and gloved, hair covered, combing through a young person’s hair looking for nits. I can answer most questions about lice, in case anyone is interested.

How to Legalize Marijuana

My interview on CBC’s The House had such a positive reception that I wanted to follow up with a short essay summarizing most physicians’ recommendations for legalizing marijuana. My own perspective is that of a psychiatrist whose patients are all adolescents and young adults. This means I am concerned about the short-term impact of marijuana intoxication in the young people that I see, but I am even more worried about the long-term impact of cannabis on the developing brain as well as the links between cannabis use and psychotic illnesses.

Most physicians hope that the federal government will approach the legalization of marijuana emphasizing public health concerns as the most important consideration in the drafting of legislation. There are also law enforcement and government revenue aspects of the legislation but in jurisdictions where these considerations were emphasized, health outcomes were affected. Doctors in Canada – and Canadians in general – will find that negative health outcomes will eliminate any possible benefits to legalizing and regulating marijuana.

The government’s vision is to have marijuana legally available for non-medicinal purposes by Canada Day 2018. For the implementation to fully consider the public health implications, the government can look to its experience with the legalization and regulation of tobacco and alcohol. There are lessons to be learned from this experience from a public health perspective and I hope Canadians can benefit from that experience. We can also learn from those countries and jurisdictions that have already legalized marijuana. Also, now is the time to set up an evaluation and research agenda to ensure that we continue to learn from our experience with legalizing marijuana.

Some of the main health concerns with marijuana are related to its impact on the developing brain. The brain continues to develop until age 25 and there is significant evidence that cannabis use interferes with brain development. While it would be ideal if the minimum age to purchase marijuana could be 25, Young Canadians are already using twice as much marijuana as any other age group in Canada. Young Canadians also have a higher rate of cannabis use than youth in any other G8 country. With use being this high (20% of Canadians aged 16-24), it is more realistic to focus on reducing cannabis use to the extent that is possible. The Canadian Medical Association recommends setting a national standard where minimum legal age for purchasing marijuana would be 21, but with restricted strength and purchasing limits until age 25.

As well as brain development, child psychiatrists have also noticed increased prevalence of psychotic symptoms in young people using marijuana. We notice that psychotic symptoms emerge at a younger age for those with a predisposition for these conditions who use marijuana. We also notice that cannabis use is associated with the more serious chronic symptoms of schizophrenia.

Many physicians are also concerned that that rigorous research has never been applied to whether marijuana has any medicinal value. Marijuana has been available for medicinal purposes in Canada for many years, but there are few, if any, studies confirming its efficacy. Given the health risks, is it not time to insist on research to determine whether medicinal marijuana is effective?

Finally, one of the most important public health impacts will be related to the consequences of driving while intoxicated.  One’s capacity to safely operate a motor vehicle after using marijuana can be affected for as long as 6 hours after use. There is no currently no adequate way to identify or evaluate whether a driver is under the influence of cannabis. A method to evaluate intoxication must be developed before legalization. In this regard, the experience of Colorado should inform Canadian legislators. This excellent review outlines the increase in traffic accidents and Emergency Room visits since marijuana was legalized. Traffic accidents are one concerns but there are others. Colorado legislation was focused primarily on the revenue generating aspects of marijuana legalization. The negative health outcomes should be a cautionary tale for Canadians.

I have focused on those aspects of marijuana legalization that are most important in my practice but the Canadian Medical Association prepared a detailed submission for the Government of Canada Task Force on Marijuana Legalization and Regulation. Canadian doctors and the Canadian Medical Association are extremely concerned about this legislation. Great effort has been taken to alert the federal government to the risks involved in legalizing marijuana. I mentioned earlier that I wished the legal age to purchase marijuana could be 25. I can see how unrealistic this is, given how much marijuana young Canadians use right now, when it is not legal. After the fact of negative health outcomes from legal tobacco and alcohol, Canadian governments have had to launch massive public health and education campaigns. It would be good to roll these out now, in the hope that we can avoid some of the negative health outcomes doctors know are coming.

Benjamin Franklin made what must be one of the first public health statements in America. We can remember this as marijuana legislation moves forward, even if Colorado didn’t:

“An ounce of prevention is worth a pound of cure.”

Does Ontario Have A Gun Problem?

Adolescents have been the focus of my practice in Psychiatry for more than twenty years.  Adolescent boys have a complicated relationship with violence and anger and it is not unusual to see that erupt, especially when they are struggling with symptoms of mental illness. It almost seems as though, at some point in adolescence, men must work through what their relationship with violence will be. As they do this work, the entire course of their lives can be affected by the lethality of the weapons they have at hand. A gun is never a helpful accessory for a young man struggling to understand and cope with violent urges toward himself or others.

Why am I thinking about guns? I have just returned from Boston and early in March I spent a week in New York City for the Commission on the Status of Women. As a Canadian, I am always more cautious when walking by myself, especially at night, in American cities. This is because, as a Canadian, I believe that there are many more guns in these American cities than in Canada. Public health research has shown that guns are a health risk.

Having said this, both Boston and New York are managing gun violence while Toronto, a city where I spend much more time, has seen spikes in gun violence in 2016 and increasing gun violence in 2017. Even in Ottawa, the capital city known for its general safety, had a higher than normal number of shootings in 2016 and 2017 is showing the same worrying trend.

Canadians often smugly think that gun control manages gun violence and, while all evidence supports this, these recent trends need to be considered. These increasing numbers mostly reflect violence involving the young men under 25 I mentioned at the outset. We know that young men’s brains continue to develop into their twenties and most parents of young men certainly notice this. This is true even though, by age 21, most young men have undertaken significant responsibilities related to education and work, and often families or relationships.

During the period of late adolescence and early adulthood, young men are at higher risk of being perpetrators and victims of violence. Over many years, there has been much speculation on why this is the case. Research cites adaptive advantages from our past to the economic disparity and racial tension that is believed to fuel violence around the world.

The one factor that has kept this violence from becoming lethal has been access to a weapon, usually firearms, that immediately make an attacker much more dangerous. In fact, countries that implemented gun control saw the number of multiple murders significantly decrease. This fact alone is the number one reason to implement gun control. Gun control is the perfect example of a public health measure based on the number of deaths and injuries it prevents. With this in mind, we need to ask, is there now increased access to firearms in Ontario to account for these spikes in gun violence?

There has not yet been an analysis that allows us to answer this question. In a country with gun control, a policy that has helped maintain public safety for so long, we need to be certain that we take this increase in gun violence seriously. Experience has taught us that gun control measures can make a difference in preventing injury and death.

Those of us who are the parents of young men, or who have been young men, or have been the caregivers of young men in distress know what can happen when frustration takes over from a youth’s better nature. A young man with a gun can do much more harm with a firearm than with his fists, or a knife. We know from the crime statistics that more and more guns are aimed at others, but many of these young men also aim at themselves.

The point is that there are more victims. We often decry that police are not attuned to the mental health problems of those they arrest. However, those of us who are concerned with health need to provide some support to the police and other agents of the law with respect to the increasing number of guns in Canada. The health impact is increasing along with the crime rate. Those of us who specialize in adolescent health must begin to understand the law as it relates to our patients.