Three profiles of opioid users

The fish-bowl lives of drug users on the streets of downtown East Vancouver provides an easy, but distorted, window to drug use. That picture is as distorted now as it was 139 years ago when B.C.’s second premier, Amor De Cosmos, headed a commission to investigate opium use.

The window to most drug overdose deaths is closed. Typical victims are single men, in the prime of their life, who die alone from opioids containing fentanyl according to a report from the BC Coroners Service released last Thursday.

Michael Strange. image: Globe and Mail

Even reports of typical deaths are somewhat distorted. For some opioid users, the drug is a godsend. Take the case of Michael Strange. He injured his back while working as a cameraman and found opioids to be the only treatment that provided relief.

“I’ve tried so many different things for my pain,” said Strange. “People say, ‘Have you tried acupuncture?’ Yeah. I’ve had two different kinds of laser therapy. I had doctors and friends say I had to try marijuana. I got the vaporizer and it did nothing for my pain (Globe and Mail, September 7, 2018).”

It wasn’t easy but Michael Strange finally found a doctor who would treat him. Many doctors were “running scared” because they didn’t want to be seen to be contributing to addiction. Now his pain specialist gives him a two-month prescription and before renewing, asks: “Michael, how are you? Are you OK with the drugs? Do you need more? Do you need less?”

Self-medication turned deadly for Chris Willie, a university lecturer with a PhD in environmental physiology from UBC Okanagan. He wrote memoirs about his recovery from fentanyl addiction but he died from an overdose before they were published. With the approval of his family, his memoirs were published in the September, 2018, edition of the Walrus. He describes his mental pain as a child and the calm he found in taking dangerous risks:

“I have never excelled at coping. I was that infant child who hammered his head on the ground when frustrated by anything at all. It must have been embarrassing to parent the son with the ever-present forehead scabs. Perhaps I found it soothing, because, thirty years later, I still find serenity in chaos and derive calm from risk. By fighting to live through near-death situations, I could find the high I needed to briefly escape the pain.”

Like Michael Strange, Emily Wharton lived a productive life with opiates. The twenty-year old opium smoker from Victoria, told a House of Commons Select Committee on Chinese Immigration of her use. The federal committee was initiated by John A. Macdonald in 1879 and headed by B.C.’s second premier, Amor De Cosmos (a.k.a. William Alexander Smith).

Back then, the stereotypical opium user was Chinese. They lured good white women into lives of depravity in opium dens. The real agenda of the committee was to rid Canada of Chinese immigrants.

Wharton’s testimony 139 years ago is recorded in Dan Malleck’s book, When Good Drugs Go Bad. She told the committee that she had been using opium for four years and suffered no ill effects. Wharton testified that opium’s “somnolence and complete rest” left her productive. Chinese men in opium dens treated her well and she objected to the characterization of the dens as depraved. She suggested that if the government legalized opium, “one need not have to come into such holes as this to smoke (p. 102).”

Medical-grade opioids are not the problem. The social stigma of drug use that drives users to overdose, and the lack of pain-treatment specialists, leads mostly young single men to self-medicate, and to die, alone.

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Normalizing the voices in our heads

Hearing voices is often regarded as a sign of mental illness. But maybe voices are just part of a spectrum.

image: The Atlantic

Professor T. M. Luhrmann says the idea of a continuum of voices is gaining recognition:

“This is the new axiom of the psychotic continuum theory: that voices are not the problem. The problem is the way people react to their voices.” says the professor of Anthropology at Stanford University (Harper’s magazine, June, 2018).

Luhrmann has been studying voices for decades and found people with intense experiences who aren’t psychotic.

One of them is Sarah, who was only four when a “spirit guide” appeared to her. When she told her mother of what she was seeing and hearing, her mother warned: “Cut it out. This is what they put people in psychiatric hospitals for.”

Sarah grew up otherwise normal, went to college and became a nurse. She began to see souls as they left the bodies of dying patients. They often gave her messages to give to people they’d left behind. While she could hear them, she realized that no one else did.

At sixty-two, Sarah is married and still working. One of her voices, “Tom,” is friendly. Other voices, “the council,” not so much but Tom helps mediate between the two.

“But Sarah is not psychotic,” says Luhrmann, “To use the language of psychiatric nosology [classification of diseases], she has no ‘functional impairment.’ She can work and care for herself and others; her marriage is good and stable. She has never been hospitalized.”

Sarah describes the council’s voices as if they are coming from a radio which would tune in and out.

My mother used to describe something like that: voices that that seemed to be coming from a radio; indistinct and sometimes with music. She would try turning off the radio only to find it was already off.

As an electronics teacher, people sometimes approach me with what I call the “radio phenomena.” They would wonder what the electronics were behind the indistinct voices they heard, seeming to come from a radio. While people can pick up strong radio signals as a result of metal oxides in tooth fillings, it’s rare and only works with strong AM signals. I was generally at a loss to explain the phenomena but it’s starting to make sense now.

Sarah has learned to live with her voices but others struggle. Schizophrenics have traditionally been prescribed antipsychotic medications with limited results.

One grassroots movement called Hearing Voices is offering an alternative approach to medication. They encourage those who are tormented with voices to address them. It’s difficult because the voices are frightening.

Luhrmann met one man at a Hearing Voices workshop. “His voices would yell at him for hours, cursing him, screaming that they should drag him out to the forest and leave him to die in the leaves.” He was encouraged to placate them. One of his voices was obsessed with Buddhism, so he agreed to read Buddhist texts and offer prayers during an allotted hour. Within a year, he had almost completely transitioned off medication.

Rather than treating voices as a disease, a better plan might be to treat them as part of rainbow of voices -some relatively benign, some requiring therapy.

“The central insight of these methods is that the way people respond to their voices can change the course of their lives,” says Luhrmann.

Advice to TRU: educate, don’t prohibit cannabis

Thompson Rivers University plans to prohibit the recreational use of cannabis on campus. This, despite the failure of prohibition to deter use for the last 95 years in Canada.

image: SchoolFinder

Cannabis is not harmless. Inhaling smoke, be it from wildfires, tobacco, or cannabis carries risks. But banning cannabis is not the way to control those risks.

Education is. Education has reduced the consumption of tobacco. Reductions have been especially greater for those with a higher education according to a report from Statistics Canada.

TRU has nine designated locations where tobacco and medical marijuana can be smoked. Once cannabis is legalized on October 17, those locations would be a logical place for recreational cannabis smokers as well.

TRU’s Joint Occupational Health and Safety Committee voted on March 5, 2018, to ban all smoking of recreational marijuana on campus for health and safety reasons. Chris Montoya, committee member and Senior Lecturer in Psychology, says not all of the 20-member committee agreed:

“Pro-marijuana smokers on the TRU committee argued that marijuana smoke is no different than cigarette smoke and that smoking areas designated for cigarette smoke should also be used for marijuana.”

But they were apparently swayed by arguments  presented by Montoya: cannabis is more potent than ever before, bystanders can get stoned from second-hand smoke, and marijuana has been linked with psychoses.

Montoya is a member of the National Advisory Council (2016-18) and the Partnership for a Drug Free Canada. He repeated some of his claims to Kamloops This Week:

“A student cannot get drunk walking next to another student drinking a beer. However, students, staff and faculty can get stoned breathing in second-hand smoke.”

Ian Mitchell, Kamloops Emergency Physician, disagrees:

“There have been a series of studies in which non-smokers are shut into a small room with cannabis smokers and tested for both impairment and positive urine tests. While these things can happen, it is only under the most extreme circumstances,” he told me by message.

A doctoral student in clinical psychology at UBC Okanagan also disagrees with Montoya:

“Researchers at John Hopkins University have been conducting studies on the effects of cannabis smoke exposure to non-users and have found that, under regular indoor conditions, non-smokers did not experience changes in cognitive ability –i.e. ’get high,’” says Michelle Thiessen in a letter to KTW.

There are places on campus for students and staff to drink alcohol as well as smoke cigarettes. TRU spokesperson, Darshan Lindsay, told CFJC Today: “There are a lot of regulations, systems in place to promote responsible use of alcohol. We just don’t have that in place for cannabis. For the university, recognizing that we are a place of education and that we want to promote an environment that’s safe and healthy for everyone, our position is that recreational cannabis should not be present on campus.”

Failing to have a “place for cannabis” perpetuates the notion that prohibition will reduce cannabis use. Banning cannabis has a predictable effect -it simply drives consumption into the shadows and prevents dealing with the risks.

TRU should become a model in harm reduction, as “a place of education.”

Prohibition is futile: TRU might as well prohibit wildfires -it would be as effective.

 

Let’s finish the job and implement Pharmacare

Medicare is a good idea but incomplete without Pharmacare. Let’s finish what we started in the 1960s. The plan was always to finish our health care system but realization of that dream got lost in perennial federal-provincial squabbling.

image: Green Party

Canada is an anomaly among nations. We are the only industrialized country with a universal public health care system but no Pharmacare.

Every study of Canada’s health care has identified the lack of Pharmacare as a major gap in our system.

Medicare without drug coverage doesn’t even make sense. What good is a health care system that prescribes drugs but doesn’t cover them?

What we now have is a mess. Drug coverage in Canada consists of a patchwork of 100 public and 100,000 private insurance plans. Some working Canadians are covered by employer-funded private plans. Seniors and those on social assistance are covered by publicly-funded provincial plans. Indigenous people, military members, federal inmates are covered by federal plans. Low-income Canadians struggle. In B.C. they have to pay up to the deductible amount.

Studies show that some low-income Canadians go without prescribed drugs because they have to buy groceries and heat their houses first. Women typically suffer more than men. Nearly two million Canadians reported not being able to afford one or more drugs in the past year. Unfilled prescriptions result in an additional burden on our health care system –patients end up going back to their doctor or to the hospital.

What we have is a mess and it’s ridiculous. When I go to the hospital, prescribed drugs are covered by Medicare and dispensed from the hospital pharmacy. When I walk out the door of the hospital, I’m on some other plan if I’m lucky, no other plan if I’m not.

The model of Medicare provides a good template for Pharmacare. While Medicare is universal in that it covers everyone, it is not universal in that it covers everything. This is especially true for Pharmacare as technology offers ever more expensive remedies. Pharmaceutical companies are coming up with new, expensive, drugs. Some are only marginally better, some no better than generic drugs. Pharmacare should not cover every conceivable pharmaceutical.

Drug spending in Canada has grown significantly over the past few decades, from $2.6 billion in 1985 to $33.8 billion in 2017, and the share of GDP spent on drugs has more than tripled from 0.5% to 1.6% over this period.

Pharmacare will reduce the amount we pay for drugs. Canadians pay among the highest prices and spend more on prescription drugs than citizens of almost every other country in the world. Among Organization for Economic Co-operation and Development (OECD) member countries, only the United States and Switzerland spend more per person each year on prescription drugs and pay higher patented drug prices than Canada.

The bickering between the federal government and the provinces over Pharmacare must stop. Now’s our chance. The federal government has opened a dialogue. What do you think? You can answer the questionnaire and make a submissions until September 28.

 

‘No Jab, No Pay,’ not here

Australia has a blunt way of getting parents to vaccinate their children called ““No Jab, No Pay.”

image: Forbes Phoenix

As the name suggests, parents don’t receive welfare payments, tax benefits, and child-care rebates if they don’t vaccinate their children. It can amount to $15,000 annually.

Not only do parents lose payments but unvaccinated children can be barred from daycare and schools during disease outbreaks. Daycares that allow unvaccinated children can be fined up to $30,000.

The exceptions to vaccinations are those children who have some medical condition such compromised immune systems or cancer. These children have a genuine reason not to be vaccinated; and these are the children who can benefit most from everyone else being vaccinated.

Australia has one of the highest vaccination rates in the world. But rates only improved slightly since the ‘No Jab, No Pay’ policy was implemented, from 90 per cent to 93 per cent. The improvement was not entirely because of the threat. A key to their success is a national registry. Health reporter Andre Picard says:

“We should not forget either that, in addition to financial penalties, Australia greatly improved its monitoring of vaccination. Having a register that shows what vaccinations children have – or haven’t – received has contributed greatly to bolstering rates (Globe and Mail, July 9, 2018).”

While it seems effective, it’s not appropriate for Canada. We are similar to Australia in that we are both former British colonies but Australia’s culture is different than Canada’s. Perhaps it’s because they were a former penal colony that the big stick approach is more accepted.

Canada has a hodgepodge of provincial systems with no consistent registry. We need to do better. We now have an immunization rate estimated (because we don’t know) to be 85 per cent. Herd immunity requires rates of 90 to 95 per cent.

There are many excuses for not vaccinating children. One is selfishness. If sufficient numbers of other children are vaccinated, herd immunity protects my child.

These parents don’t remember, or never knew, what it was like when vaccinations didn’t protect against diseases like polio. I do. I remember growing up in Edmonton during the “polio season” when epidemics of the crippling disease raged in the summer and fall. Provincial public health departments tried to quarantine the sick, closed schools, and restricted children from travelling or going to movie theatres. My uncle survived polio but walked with difficulty with the use of a cane and died prematurely because of polio complications.

Another reason is the irrational fear that vaccinations cause disease. While these hard-core anti-vaccination parents receive a lot of press, they only number about two per cent. The other 13 per cent fall into the categories of complacency, those who doubt the necessity of vaccinations, and those who just don’t’ find it convenient to get the vaccinations done.

Convenience is a big factor. Parents don’t get around to vaccinating because it takes time and effort. One-on-one attention is sometimes all it takes, such as an email or phone call reminder.

Canadians need to be encouraged, not bullied into improving or vaccination rate. We need a national registry. Improved rates will provide immunity, not only for their own children but for those vulnerable children who are unable to receive them.

When am I dead?

When I’m dead I won’t be writing these columns. But other than that, indication of my demise might not be certain. The problem is that our definitions of death vary according to legal, cultural, religious and philosophical perspectives.

  image: slideserve.com

There was some dispute about whether Taquisha McKitty of Brampton was dead. Doctors said she was but her parents disagreed. She went into cardiac arrest following a drug overdose and was declared neurologically dead. A death certificate was issued.

McKitty’s father said: “My daughter is not dead -she shows that every day.” He maintains that his daughter shows signs of life: squeezing the hands of loved ones and even shedding tears.

Whether she was living was finally decided through a court decision. A judge ruled that McKitty was, in fact, dead.

Keeping someone alive with life support is not an issue. Canadians are kept alive with pacemakers, kidney dialysis, mechanical hearts and lungs while awaiting transplants. The issue is whether we should maintain one’s bodily functions when they are dead.

McKitty’s family might disagree with my last sentence. If they believe that bodily functions define life, then the squeezing of hands indicates that Taquisha was alive.

Others could argue that breath itself is life. If so, breathing is an indication of life. Genesis 2:7 says: “The LORD God formed the man from the dust of the ground and breathed into his nostrils the breath of life, and the man became a living being.”

Still others believe that the soul, the essence of life, resides in the heart. The ancient Egyptians thought that the heart was vital. During mummification, they discarded the brain by removing it through the nose but kept the heart. They likely believed that as long as the heart is pumping, a person is alive.

In Western culture, the brain defines life because it’s the seat of the mind. Some philosophers suggest that it’s the mind that defines life. They argue that since the mind resides in the brain, and because the brain is a (biological) machine, the mind could reside in any machine. If complex computer could be built, the mind could continue to live in a solid state environment without a body.

The Japanese would disagree. They see the body and mind as a single unit so that the mind is not independent of the brain. To be alive is to experience bodily sensations and desires as well as cerebral thoughts.

The judge in McKitty’s case ruled that the brain is central in determining death. If the brain is dead, so is the mind. This opinion coincides with doctors’ assessments. Dr. Sonny Dhanani, a pediatric critical care physician in Ottawa, concludes:

“When brain death occurs, there is no blood and oxygen going to it. The brain ceases all function. There are no functions left to be lost. This means there is the irreversible loss of any ability to have thoughts or feelings or memories (Globe and Mail, July 6, 2018).”

I won’t know when I’m dead and given the definitions of life, maybe no one else will be sure any time soon.

Homophobia contributes to loneliness

Men haven’t always avoided open displays of affection for each other. Rachel Giese author of Boys: What It Means To Become A Man says:

“Our squeamishness about male friendship is a historical anomaly: connections between men have been idealized throughout Western history and understood as foundational to society, culture, and art. The veneration of men’s friendships can be charted as far back as ancient Greece (Walrus magazine, May 2018).”

  image: Mental Floss

Before the mid-1800s, society was structured around organizations of men –guilds, religious orders, service clubs, sports teams and the military. Displays of affection and confessions of love between men were common and unremarkable. In his essay “On Friendship,” French philosopher Michel de Montaigne describes his relationship with deceased friend as one with “souls mingling and blending with each other so completely that they efface the seam that joined them.”

Such gushes of emotion would be suspect in today’s society. Even the innocuous term “bromance” carries a certain discomfort. “It celebrates same-sex fondness,” says Giese, “but does it with a smirk—as if two men caring for another needs to be explained or justified.”

Culture changed at the start of the twentieth century as women became more integrated into public life. Schools, places of work, and politics were no longer the exclusive domain of men. Marriage shifted from an arrangement between families to one based on romance and love. The nuclear family replaced the male-dominated associations as the centre of culture and society.

Victorian values made homosexuality a perversion and a threat to social order: platonic friendships became suspect. These values resist change. Men are defined as the opposite of women, the head and provider of the family -and heterosexual. In this context, homosexuals are seen to be the opposite of a “real man.”

Homophobia has a toxic effect on boys. Professor Niobe Way has studied the emotional landscape as boys mature. The common notion is that boys are less communicative, invulnerable and less capable of intimacy, than girls. However, Professor Way found genuine affection among boys. One fifteen-year old told her of his feelings for another boy: “[My best friend and I] love each other…. I guess in life, sometimes two people can really, really, understand each other and really have a trust, respect and love for each other. It just happens, it’s human nature.”

As adolescent straight boys approach manhood, the fear of being perceived as a homosexual grows. They leave behind friends as they explore the uncertain terrain of romantic relationships of women. They are vulnerable as they no longer have a foot in either world.

Professor Way believes that young men are suffering from a “crisis if connection” as a result of being told that real men can’t be close to each other. Men can end up lonely at a cost to their health. Former U.S. Surgeon General Vivek Murthy speaks of loneliness, isolation and weak social connections:

“[They] are associated with a reduction in lifespan similar to that caused by smoking fifteen cigarettes a day and even greater than that associated with obesity. Loneliness is also associated with a greater risk of cardiovascular disease, dementia, depression, and anxiety.”