Changing the way we think about addiction

It's Friday evening, 19:30, and you're the only doctor left in the emergency department. It's been a busy day and you're tired, but you don't finish for another hour and a half. You are still working up 2 patients with chest pain, and 2 weak and dizzy's, one of whom arrived by ambulance without any actual medical information. There are still 10 charts in the 'to be seen' pile and you know the evening rush will soon follow. You're flagging...

One of the nurses, equally exhausted, walks away from curtains shaking her head and hands you the chart of your next patient. The face sheet lists the reason for visit as 'Needs Dilaudid Rx'. You walk in and see the patient, obviously agitated, pacing the room. "How come it takes so long to get help around here? What kind of emergency room is this? This place is full of idiots!" Struggling to get a word in you try to take a history. After some hard work you glean that the patient is usually on Dilaudid Contin 12mg BID (or 'Dilly 12's', as the patient refers to them) for chronic pain due to a chronic leg ulcer and osteomyelitis of the tibia. "My stupid doctor went away for the weekend without filling my per", the patient says, "Just give me a week or so worth until I can get in to see him, I haven't even had any today, and I'm in PAIN!".

You do a detailed physical exam and find a large, deep chronic wound on the patients shin with significant surrounding cellulitis. You also note that the patient has track marks around the left elbow, and appears to have significant oral thrush.

Addiction can be a frustrating issue for doctors and other medical professionals. Most doctors are ill equipped to handle most patients with active addiction, and for many doctors the above patient is a nightmare. That frustration is evident in many popular med-blogs, which frequently contain posts venting about patients like the one discussed above. It's useful to consider where that frustration comes from because it clearly makes the jobs of many doctors miserable, and it also gets in the way of good patient care.

Frustration in caring for addicted patients comes from a number of places:

• Addictive behavior is often manipulative, and manipulation makes people angry.
• Doctors often don't have an approach to managing patients with addiction.
• Doctors often feel like they cannot help patients with addiction, and are therefore wasting their time.
• Addiction is a common disease and most people have at least one friend or family member who has struggled with addiction. Patients with addiction can bring up uncomfortable memories and feelings for doctors.

Developing approaches and strategies to effectively treat patients with addiction results in benefit for both patient and doctor. The patient accesses effective, evidence based care and allows the treating doctor to feel like they are offering the best available options to the patient. I am not arguing for the Emergency Room to become the main treatment ground for addiction, however as it frequently sees patients who are struggling with addiction it makes sense to develop approaches to treatment that start in this environment, both in the interest of good patient care as well as in the interest of job satisfaction of the people who work in the emerg.

Like many other conditions that we treat with modern medicine, addiction can be understood in terms of a bio-psycho-social model. That is, the inputs into the condition of addiction come from a number of places. Does addiction run in your family? Did you grow up in a high risk environment? Were you exposed to potentially addicting drugs in utero, or during your youth? Do you work in a high risk profession (like being a doctor)?

All too often the issue is polarized into an argument of 'It's a choice!' versus 'It's physiology and genetics!'. It's both, just like Type II Diabetes, a condition that has a lot of common ground with addiction. Type II diabetes is a condition resulting from some combination of genetics, family eating patterns, social situation, patient choices and patient environment. Both are diseases that involve elements of patient personal choice, as well as patient physiology. Good treatment for both addiction and type II diabetes involves far more than just medications (though in both circumstances medications often have a role to play). Usually the most effective approach is a team approach. In the case of a diabetic that might be a doctor, a nutritionist, a pharmacist and a personal trainer. In the case of an addict it might be a doctor, a counselor, a peer support group and a parole officer. In both cases the system works for the patient when the system works together.

Addiction is a long term, chronic condition. Gone are the days of sending people off to treatment centres for the cure. Treating addiction is not a win-loose proposition. Management of over the long term involves helping patients move towards change and abstinence, once abstinence is achieved it involves relapse prevention and management of relapse. Over the long run it involves reducing both the duration and frequency of relapse. When relapse happens (and it does happen because it's part of the long term reality in addiction) it makes sense to approach it from a management standpoint. Just like managing a diabetic who comes in with an A1C of 12% after a year of good control, it makes sense to figure out what happened, what changed, and how do we make changes to get things back on track.

Addiction is common, with lifetime prevalence usually estimated at around 5% of the population. Addiction is associated with a lot of serious medical issues including Hepatitis C, HIV, cirrhosis, brain injury and premature death. Considering interventions that may allow patients to avoid these serious consequences makes sense on both economic and compassionate grounds. Emergency room doctors have the misfortune of usually seeing addicted patients at their worst, and rarely see them when they improve. It's a tough environment to convince people to take an interest in addiction, but it's an area where it makes sense to develop approaches to the issue.

Most doctors have been taught to recognize the patient I presented earlier in this article as drug seeking, and that the treatment options are either to provide a small amount of narcotics, or to tell the patient they can't have narcotics and discharge them. It's a conflict oriented approach that both frustrates the doctor, and the patient.

My own approach to patients like the one above is to frankly tell them that in my assessment they seem to have an addiction problem and that it looks like it's having some serious health consequences for them (in this case both the infection, and the HIV that the thrush hints at). I tell them that I'm glad that they came into for help and offer them help. I offer them medical detox, and tell them that I'll go to bat for them to get them the help they need. I tell them to think about it, that it's their decision, and I'll come back in a few minutes to see what they want to do. (In clinic I take a bit of a different approach I won't get into here.) The benefit of the approach is that I feel like I've offered the patient the best treatment possible, and I've hopefully caused a moment of ambivalence for the patient where change might be possible.

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The patient presented above is fictional.
If you are struggling with an addiction and want help talk to your doctor or click on the links to alcoholics anonymous, narcotics anonymous or cocaine anonymous on the right, and find a meeting near you. Change is possible!

The Northmed Index (or please don't sue me Harper's magazine)

I like to think of myself as a minimalist for stuff. I function fine with what I can fit in a suitcase for a month or more, and rarely think 'wow, I wish I'd brought along X'. There's only a month left until we move from Vancouver to Iqaluit, and that means it's time for packing. Let the good times roll; packing is one of the most stressful activities around. Today an estimator for the moving company came by to see how much stuff we have to move up north. It's a real dilemma, do we take a little or a lot, do we store everything or take it along? Although the moving guy confiently said 'You've got less stuff than lots of people, I still feel like we've accumulated clutter since we came to Vancouver. Moving will be a great way to thin it all out. Here are a few facts and figures about our house, our stuff our city(s) and our life.

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Vancouver coordinates: N 49 16' W 123 7'
Iqaluit coordinates: N 63 45' W 68 31'
Size of Vancouver: 114 square kilometers
Size of Baffin Island: 507,451 square kilometers
Average Janurary temperature in Vancouver: 3 C
Average July temperature in Vancouver: 18 C
Average price of a home in Vancouver (March 2007): $705,141
Final selling price of the tear-down, former grow-op house across the street from our apartment: $910,000
Number of rooms in our apartment: 6
Number of TVs: 1
Number of Computers: 4
PCs: 2
Macs: 2
Percentage of computers that can complete a functional boot up: 50%
Percentage of functioning computers that are Macs: 100%
Average February temperature in Iqaluit: -26.4 C
Average July temperature in Iqaluit: 7.7 C
Minimum operating temperature of the Macbook computer: 10 C
Population of Vancouver: about 2,000,000
Population of Iqaluit: about 8,000
Number of RAV lines in Iqaluit: 0
Number of RAV lines in Vancouver: 0 (still under construction)
Number of hospitals in Canada (approx.): 830
Number of hospitals in Nunavut: 1
Percentage of Canada's total area occupied by Nunavut: 21%
Number of Canadian hospitals further north than Baffin Regional Hospital: 1 (Inuvik Regional Hospital)
Suicide rate for Canada: 14 per 100,000 per year
Suicide Rate for Nunavut (2006): 123 per 100,000 per year
Approximate return airfare Toronto to Iqaluit: $1750
Approximate return airfare Toronto to Bangkok: $1750
Average January temperature for Bangkok: 32 C
Number of days until we move to Nunavut: 19
Percentage of packing completed to date: 0%

Aquariums Galore!

Yesterday I went to the Vancouver aquarium with my brother, sister and nephew. I admit that I am an aquarium nerd and have a salt water tank at home, though it has suffered from neglect of late (don't worry, the fish are very happy swimming in the algae.....happier in fact than in the algae free tank they used to live in when I was spending more time on this hobby). One of the amazing things about the Vancouver aquarium is that it has a great deal of cold water exhibits from local environments here on the west coast. While reefs, are usually associated with the tropics, the cold water reefs of the west coast are colorful and full of interesting marine life....
Here are a few pics I snapped along the way....

A beluga whale....I don't really think these guys should be in captivity, but they are, and here's a picture.


Mmm, it's a jelly (that's a Bob and Doug MacKenzie reference that Canadian readers will hopefully get).


My nephew posing like the aquarium ad (He is a monstrously tall 1 year old in case anyone is wondering).


Cold water fish and anemones.


Another cold water tank.


My aquarium, before it became an algae jungle.

Advances in Northern Medicine

Frostbite is a common injury both in northern settings as well as in more unexpected places. Working in the arctic over the last 6 months I've seen quite a number of frostbite cases, but even when I was working in Vancouver I'd see the occasional frostbitten patient. That's right, Vancouver, Canada's tropics, has frostbite. In Vancouver frostbite is uncommon, but working on the Downtown Eastside I did see a couple of cases in homeless folks who had weathered a cold night outside with wet feet in poor footwear.

An article in this months Archives of Surgery, entitled Reduction of the Incidence of Amputation in Frostbite Injury With Thrombolytic Therapy, describes the use of intra-arterial tPA in patients with frostbite injury to a digit and demonstrated impaired perfusion. The article concludes by proclaiming that this is the first clinically significant advancement in the management of frostbite in more than 25 years. Indeed, as any northern doc can tell you, management of frostbite is limited.

A patient presents to the emergency department after passing out in a snow bank. Surprisingly his core temperature is adequate, but his hands appear white and frozen. At present the standard treatment for this patient involves:

• pain control, usually with IV narcotics
• rewarming of his hands by immersion in saline warmed to 42 degrees C
• treatment of any hypothermia (with external, and often central rewarming)
• debridement of any blisters containing clear or white fluid (these blisters represent more superficial injury, and contain PGF-2A and thromboxane, both of which can cause deeper injury through inflammation)
• Hemmorhagic blisters are left intact as debridement can lead to increasing depth of injury, though aspiration can be considered.
  
• Administration of an anti-inflamatory drug (Ibuprofen)
• Tetanus booster if required
• Telling the patient that they may not, under any circumstances, smoke (most people are able to not smoke when their fingers are at risk)
  
• Surgical consultation (though early surgical intervention is avoided if possible, as even horrific looking injuries sometimes recover well)

The article suggests that the use of intra-arterial tPA may represent an advance in therapy that may save digits. This is exciting news to anyone who deals with frostbite, because at present effective interventions are limited, and poor outcomes can be disabling. There are limits to the study however, (small size, non-randomized, case control design, restriction to a single highly specialized institution) that prevent this from being a definitive and practice changing study. Certainly these results warrant a larger, multi-centre, randomized investigation. Given that many frostbite injuries occur in the periphery where timely access to intra-arterial thrombolysis is non-existent I do wonder if an arm of such a study examining systemic thrombolytic therapy might be warranted (though the risks of systemic therapy are also greater).

The blog debate continues...

The debate around blogs and libel law continues in today's Globe and Mail (Canada's national newspaper, in spite of my props to the Nunatsiaq News on my links bar). The article, entitled 'Media stardom is pricey', discusses the relevance of these issues here in Canada, and points out that we Canadians may not enjoy all of the same legal protections as our American colleagues, particularly with regard to libel resulting from posted comments from readers.
It's worth a read...

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Here is the comment I posted to the G&M website about the article....

Blogs are, at present, an important communication tool for young people. Whether they will go the way of the 8-track or the television remains to be seen.
As a physician maintaining a medical blog (northmed.blogspot.com) I am always thinking about not only any potential libel/slander issues, but also about issues of confidentiality. For me personally this has meant a non-anonymous blog, with editorial style pieces about issues in my particular realm of medicine, as well as more personal pieces and pictures. Confidentiality of course precludes any posts about patients, but to date I have also avoided any posts about fictionalized patients that might be misunderstood as a casual reader as non-fiction.
Over the past 6 months a number of medical blogs, offering very informative views into the culture and life of medical professionals, have gone off-line due to concerns about both legal and professional issues.
At their core blogs offer freedom of both freedom of speech and freedom of press to anyone who chooses to exercise that right. Of course there are limits (confidentiality and libel chief among them), but the standard to which blogs are held should be the same standard that any adequate small town newspaper may be. Erosion of free speech and free press is a serious issue, and blogs may exist on the razors edge of that debate...

The gasoline on the fire...

Burnout: A psychological term for long-term exhaustion and disinterest, in the context of work.

In the six months since I started this blog I've received a number of comments and emails from people who tell me they enjoy reading because they think this is one of the few physician blogs out there not suffering from burnout. In reality it may be that people mistake venting, present in many blogs and as much as possible absent from this blog, as burnout. Regardless, it's interesting that many people, of both medical and non-medical backgrounds, perceive so many doctors as being burned out. Burnout is an important issue for both individual doctors, who change careers, loose income, and live unhappy lives as it's end result, and also for the public because burnout chips away at an already precarious physician supply, and disengages otherwise excellent docs from the business of caring for patients. It's certainly an issue worthy of examination.

For most doctors (myself included) burnout is an idea that's loaded with personal experience, either our own or our colleagues. A year ago I found myself in a situation at work where I was at risk of burning out, and as a result had to do a great deal of forced introspection about the causes of and solutions for burnout. Much of the discussion below is based on my own experience, rather than any formal research.

Burnout is an issue that is well hidden in medical training. The general assumption during medical school is that everyone should be grateful to be there and that since medicine is a noble calling that everyone will surely love what they do. Sure there might me a lecture or two over the four years of medical school on career satisfaction, but like most of the soft content (meaning non-testable, and non-scientific), these lectures are poorly attended and easily dismissed. Even with these lectures in place most young medical trainees view themselves as different than their predecessors. With different priorities, different work styles, and different career choices, many young doctors enter practice feeling that they are not at any risk for burnout.

Medical students and residents are frequently confronted by burned out doctors during their training. These are the doctors who wander the halls spewing hatred about their patients, their colleagues, their hospital, their career, their medical association, their salary, to any and all who will listen. They are also the quietly unhappy doctors who trudge on, day after day, but in quiet moments advise trainees to select a different field, or a different road then they. Throughout medical training thoughtful introspection is actively discouraged in favor of the long view, and delayed gratification. The end result is that young doctors, after completing their residency, enter a field with a very high rate of burnout, ill equipped to either identify or deal with potential problems. Their only role models when it comes to burnout have been the frustrated, burned out docs who loudly, or meekly trudged on. Because any ability or willingness to self reflect has been thoroughly quashed during their training, they have trouble both identifying and coping with work related stress. Some enter practice already shouldering a fair amount of burnout accumulated during difficult residencies.

Although there are many causes for burnout I will focus on only 2 (lack of power/voice, and vicarious traumatization) that I believe are major contributors in the medical workplace, and for physicians in particular.

Lack of power is an issue that leads to burnout in any workplace. When you don't feel your decisions or effort is appreciated or acted on by those around you, when you don't have any control over your workplace, it's difficult to feel that the work you are doing is worthwhile. Medical residents, who are typically told where to be, when to be there, and that their efforts (however well intentioned) are simply inadequate are particularly vulnerable to this stress. Practicing physicians often have more control over their time, and more ability to make their own decisions, but can suffer similar stress in their workplace. Doctors who work in large organizations are often treated like replaceable cogs in a large machine, and although they may see real front line issues in their workplace their attempts at solutions frequently fail to percolate upwards through the filters of bureaucracy. People who feel their job is irrelevant tend to simply go through the motions, and get little personal satisfaction from work. It's a recipe for burnout.

Vicarious traumatization is an issue that many physicians are unfamiliar with. Put simply, it is that idea that being in the presence of someones suffering (particularly in an intimate way such as the doctor-patient relationship), can cause suffering of it's own. Overt examples include being present at the unexpected death of a young person, or being involved in a case with an unexpected bad outcome. More subtle examples include caring for patients who have been severely abused and hearing their stories in detail, witnessing the results of significant violence, and caring for patients on an inevitable collision course with tragedy. Unfortunately many doctors view ideas like this as intolerably flakey and prefer the age old methods of denial and compartmentalization in dealing with any unwanted personal emotional response. Particularly at risk environments for this type of burnout include any place where abnormal events occur with such regularity that they become normalized. Any workplace where tragedy is met with responses like 'Get used to it, it happens all the time here, and we don't have time to stop and talk about it.' is likely to be full of this type of burnout. Normalization of the abnormal also poses a significant risk for trainees who work in many environments for only a short time and who may not be able to participate in any of informal support mechanisms that might exist. Most doctors are exposed to situations that put them at risk for vicarious trauma. Unfortunately most are also well schooled in suppressing any such response and not dealing with their own emotional well-being. Again, a recipe for burnout.

Dealing with situations that cause burnout, and dealing with actual burnout is difficult. It requires introspection. It requires recognition that doctors do have emotional (and non-rational) internal responses to stressful situations. It requires developing workplaces that are responsive to the concerns of front line workers, and have active programs to deal with unusual (or usual) stresses. It requires that abnormal situations be named abnormal, and debriefed accordingly (workplaces that say this is impossible because they don't have enough time have a staffing problem). It requires that doctors participate in debriefing. In workplaces where these supports don't exist, it requires individuals to carefully consider whether they can maintain their own health in such an environment.

In my own situation, after a careful examination of the particular stresses of my workplace I made the decision to change my environment. I stepped out of a job that I enjoyed, but had some significant and major stresses that I felt could not be overcome. After debating the issue for a while, I felt that the most healthy thing for me was to move on (hence a northern adventure slated to begin this summer began about 6 months early). I think that part of why this blog is devoid of burnout is because I am actively trying to address issues that could lead to burnout upfront.

Burnout is a challenging issue. It forces us to confront our own reactions and feelings, and to make some difficult decisions. It always troubles me when I read about doctors who hate their job. Almost invariably they are suffering from workplace burnout, and simply aren't sure how to deal with it. There are too many options, and too many jobs in medicine for anyone to be stuck in an environment that is intolerable. Hopefully as we move towards recognition of burnout as a widespread and important issue we can help physicians develop the personal tools to cope with difficult situations as they arise, and workplaces that support this process.

Self-care is not a soft subject and should not be treated as such. Doctors can't provide good care to patients when they themselves are unwell. We all have a duty to bring our best selves to our work and to our lives, and this involves giving self-care more than the short change it currently receives.

Odds and Ends

I arrived home in Vancouver after four weeks in Inuvik last week. Like my previous trips north it was an amazing experience. The Western Arctic is vastly different from the Eastern Arctic not only in it's landscape, but also in it's cultures and peoples. In the east most of the traditional culture is Inuit in origin. Inuvik on the other hand sits at a cultural junction point where Inuit, Gwich'in and Dene peoples all meet. While I was in Inuvik I had the opportunity to speak with a number of Elders from various backgrounds and learn a little about the areas traditions and life.

Speaking with Elders about their experiences of change over the last century is one of the real priviliges of spending time in the north. It is often amazing what people have lived through, and wonderful to hear their perspectives. In our society speaking with older people about their experiences isn't something that's often emphasized. I remember speaking to World War One Veterans about their experiences as a grade school student, but with no real appreciation of what a precious and limited resource their memories and views were. I hope that my appreciation for the living past is something I'll take with me through my life. (And maybe one day when I'm old some grade six kid will interview me about the times before computers; 'That's right, we did math on paper.....what's paper?!?, well let me tell you it was made from trees, yup there were so many trees we could just cut them down and grind them to pulp by the thousands!')

In mid July Dr. H. and I will both be heading up to Iqaluit for a longer term contract. We are looking forward to it a great deal, and hope not only to learn more about northern medicine as we work, but also to learn about the culture and people we will have the privilige of meeting along the way.

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In case anyone thought they'd get away with out being subjected to the endless slideshow, here are some pictures of my brother Shawn and I fishing in beautiful BC!

Gone Fishing...

'I wonder what they're biting on today?' It's the middle of the week, and the lake is empty, it's overcast and a light rain is making the surface of the water ripple. 'I'd try one of those Mepps spinners.' Wild speculation, an endearing trait of all fishermen, but the weather is right so it's a safe guess.
Flip the bail. Fishing rod up. Flick your wrist. Swishhhhhh. Click. Splash. And reel.
Repeat.
Ahhhh, feel the blood pressure fall.....

As usual my lousy fishing karma reigned supreme. The 'big one' was as elusive as always. Oh well, it's more about the rythm of casting and calm anyways.

"Glad to see you're not wrecking your coronaries with doughnuts, Roy," said Pinkus. "I've tried to tell the girls but they won't listen. They're lucky, of course, in that the estrogens lower their incidence."
"I'm not hungry," I said. "I think I've caught what the BMS [best medical student] had. I'm gonna die. I just timed my respirations: thirty-two a minute."
"Die?" asked Pinkus. "Hmm. Say, did that BMS have a hobby?"
The head nurse picked up the chart, turned to the special section created by Pinkus, called "Hobbies," and said, "Nope. No hobby."
"There," said Pinkus. "See? No hobby. He didn't have a hobby, do you understand? Do you have a hobby, Roy?"
With some alarm I realized that I did not, and said so.
"You should have at least one. See, my hobbies are directed to the care of my coronary arteries: fishing, for calm, and running, for fitness. Roy, in my nine years on this Unit, I've never seen a Marathon runner die. Not of an MI, not of a virus, not of anything. No deaths, period."

Samuel Shem
The House of God