Do you suffer an addiction?

Every form of addiction is bad, no matter whether the narcotic be alcohol or morphine or idealism. - Carl Jung

For me, it is important to understand that addiction is a common humanity and opioid is just one of the many many objects of addictions.  Without this fundamental perspective, the answer, that is within everyone and requires everyone’s participation, will remain hidden from awareness.  Believing that somehow social determinants or anything external are the root causes only deepen stigma, conjures more divides and misguides the society’s attention away from the real problem.

What I see is a general lack of awareness.

The political leaders elected to better our society seem to spend too much time defending against accusation of being antisocial.  Professionals who feel powerless against imminent burnout are expected to teach, heal and lead the masses who suffer the same. Consumers who are willing to yield to what the mind want and don’t want at the horrific expense of the body, the community and the planet are looking for magic cure for the natural consequences of their questionable choices.  Opioid crisis, rising suicide rates, type 2 diabetes crisis all seem to respect no external divides - age, gender, ethnicity, social economic, education, nationality, etc. Being unaware of the many subtle addictions created yet more divides between those who suffer addictions socially unacceptable vs what’s “acceptable” (but equally harmful).

I think addiction to the mind may be a common humanity; and the expansion of this awareness is one essential component of the real solution; and it needs to begins with the individual at every meal, every conversation and every moment.

My patient asked me if I was high!

1. I think having a conversation about non-pharmacological solutions generally take more time and care; in my experience, these conversations are needed, more often than not. I also have chronic pain. Rather than blocking these pains with analgesics, I have chosen to use these experiences as opportunity to discover sustainable solutions for myself and my patients. I try to share these perspectives with my patients in a compassionate way and I find that they are well received.
   
   
3. 
   
   I just saw a long term opioid reliant patient who I have on daily dispensing. Our non-pharma interventional contract is 20 minutes of meditation daily which she does on her own in my office. At her own request, she gets routine urine drug screen. She show them to her father so that he does not call her names. I encourage her to see her father as someone in need of help rather than one who victimized her. Just now, she pushed her face close to mine and stared into my eyes and waited for me to evaluate her pupil size (opioid state). She told me she is now eating her spinach; she has gained some much needed weight; she even ate some spicy California rolls today! She then told me she is ready to reduce her breakthrough dose. I did a little happy dance as a way of acknowledging her monumental decision! She laughed and asked me if I was high! Lol!

I worked at emergency department on the weekend...

I worked ER on the weekend.
I was asked to see a 25 year old that was agitated and aggressive having had her opioid overdose reversed with naloxone. She said she wanted to leave. I asked her what is she going to do about her addiction. She said she wants to get out of here and go get her hamburger at McDonalds (she has a coupon) and then go home. She said she won’t have money to.. till Friday. I asked her what is her specialness. She then for the first time looked at me and said that she is good to others. I asked her if that means she feels others pain; and that she escapes her pain by using substances. She then started to tear up. I told her she is stuck but it does not have to be so.
I share the following perspectives with her.
1. Neurodiversity
2. Ability to choose the object of attention can be increased through meditation.
3. Object of her attention dictates her experiences… suffering or otherwise.
4. Anapana meditation by Goenka.
5. Vipassana retreat at Egbert Ontario.

She continue to cry and told me that she will study it. I emailed her a invitation to attend my weekly groups.

I believe I can easily be overwhelmed by the crisis and overlook non-pharmacological opportunities that can truly address the cause. So I remind myself that to effectively address the opioid crisis, a clear understanding of the root cause and its solution is necessary. 

On the whole, I believe opioid crisis is just one fatal symptom of a culture that is unwell. It is by no means the only fatal consequence ( Type 2 Diabetes, Increased Suicide being two more…) of a culture that has for some time forgotten the importance of individual and social responsibility. It is just one that is for now screaming at our collective conscience.

According to University and College Health Association:

http://oucha.ca/pdf/2016_NCHA-II_WEB_SPRING_2016_ONTARIO_CANADA_REFERENCE_GROUP_EXECUTIVE_SUMMARY.pdf

65 percent of students reported experiencing overwhelming anxiety in the previous year (up from 57 per cent in 2013).
46 per cent reported feeling so depressed in the previous year it was difficult to function (up from 40 per cent in 2013).
13 per cent had seriously considered suicide in the previous year (up from 10 per cent in 2013).
2.2 per cent reported attempting suicide in the last year (up from 1.5 per cent in 2013).
Nine per cent reported attempting suicide sometime in the past (not restricted to last year).

Mental health challenges seem to be the norm rather than the exception; and does not seem to go away with time.

According to CAMH:
By age 40, about 50% of the population will have or have had a mental illness.

The Canadian health care budget is already in excess of $250 Billions. It would seem that some wellness perspectives are fundamentally lacking in the contemporary mindset.

I believe, as physicians we are all blessed with great minds, society’s love and trust deserved and sometimes undeserved and the precious perspective of self-empowerment. We collectively hold the power to heal our culture of illness and lead the transformation to a cultural of compassion and wellness.
I believe to do that I must be on the wellness journey myself. Then as a family physician, I have enormous influence on many individuals at every echelon of society. People with enormous influences come to me at their moments of suffering, open to new perspectives and mostly willing to take actions. What a privileged position with wonderful opportunities!

I think an effective and affordable solution may begin by challenging everyone to have wellness conversations at every opportunity:

1. Wide adoption of Mindfulness training programs (such as Mindfulness without Border Ambassador Program) and robust nutrition education at every level of the education system: schools, colleges and universities.
(I facilitate resilience groups for medical students and will speak at a local school parent teacher meeting on “addictions and mindfulness training”)
2. Wellness role modeling and promotion by our political leaders, community leaders, celebrities and other opinion makers.
( I will speak at a community garden club on “pain, suffering and illness”)
3. Wellness programs in government and private organizations.
(I am looking for opportunities to start “employee wellness programs” at the hospital)
4. Expanded availability of group psychotherapy in primary care and beyond. (I run several weekly groups for patients in my practice and community. If you like to learn to run these groups; just ask me how!)

Thanks for reading!

What is the relationship between Climate Change and the Opioid Crisis

To truly address the opioid crisis a clear understanding of the root cause and the true solution is necessary; anything else short of that may just be more “substitutes” that hides the inconvenient truth.
I believe opioid crisis is one of many symptoms of a culture of sickness. It is by no means the only fatal consequence of a culture that has for some time forgotten the importance of individual and social responsibility. It is just one that is for now screaming at our collective conscience. It foreshadows greater calamities. I used to think that I am already trying my best and I can’t be expected to do much more than to whine and complain. Somehow I suspect I am not alone in my opinion. Yesterday, I listened to a speech delivered at the EU conference last month by the 16 year old Swedish Climate Change activist, Greta Thunberg. It was a sobering message that helped me understand my own version of narcotic. It is the narcotic of optimism that somehow the millennials and the echo generation will be more enlightened and stop the climate change, the opioid crisis, the diabetic crisis and all the other crisis I have helped perpetuate by my stuporous inaction.

I have not asked her, but I think I know what Greta will tell me to do about the Opioid Crisis or the Type 2 Diabetes Crisis….
Stop messing around with more studies or rely on others or the government to solve the problem! Take personal responsibility! Deal with my own addictions! Eat a mostly plant-based diet! Be a good example for others! Start wellness conversations at every opportunity. 

I believe, as physicians we are all blessed with great minds, society’s love and trust deserved and sometimes undeserved and the precious perspective of self-empowerment. We collectively hold the power to heal our culture of illness and lead the transformation to a cultural of compassion and wellness.
I believe to do that I must be on the wellness journey myself. Then as a family physician, I have enormous influence on many individuals at every echelon of society. People with enormous influences come to me at their moments of suffering, open to new perspectives and mostly willing to take actions. What a privileged position with wonderful opportunities! I can run groups for self-management education. I can make sure each patient knows the potential of 5 oz of non-starchy vegetables in prevention of Type 2 diabetes, Alzheimer’s disease and many many other diseases. I can help patients understand the role of pain and the true nature of addiction. I can empower them to share their wellness perspectives with their family, friends. I can collaborate with them to become changemakers in their circles of influence.

If a 15 year old Greta Thunberg can take on Climate Change; as a family physician I can surely find ways to do my part to promote wellness and compassion.

https://www.whatisharewithpatients.com/2019/03/is-every-addiction-bad.html?m=1

Is every addiction bad?

Every form of addiction is bad, no matter whether the narcotic be alcohol or morphine or idealism. - Carl Jung

However, I have also learned that what seems good is not necessarily good and what seems bad is not necessarily bad.  I think every gifts of nature or medicine of man’s ingenuity can be useful and misused.

On whom and when to use these tools may be case by case and moment by moment decisions.  

If I am dying from cancer I’d be grateful if my prescriber were sufficiently knowledgeable to help me manage with the appropriate tools.  If I suffer back pain from being sedentary and poor nutrition and didn’t know better, I’d be grateful if my doctor took the time to teach me self-management instead of giving me a way to avoid addressing the real cause of my pain and suffering by prescribing me a quick fix.  

If I am unable to manage the content of my thoughts and become preoccupied with memories of regrets and shame of the unchangeable past or fear and hope of an imagined future; I’d be grateful if my doctor took the time to share with me the potential of Breath Awareness Meditation (Anapana) as one way to gradually improve my ability to pay attention to the present moment, enjoy the vividness of each present moment, develop self-compassion and a sense of oneness, instead of only offering me a substitute of exogenous mind-altering chemical depressant, stimulant or hallucinogen (natural or synthetic).  I believe the potential for addiction of a given substance is proportional to its effectiveness in reducing the symptoms of my suffering and inversely proportional to my awareness, ability to meet my real needs and reduce the true cause of my suffering.

https://www.ncbi.nlm.nih.gov/pubmed/7042457

If I suffer pre-diabetes or type 2 diabetes (30% of Ontarians) due to my average Canadian diet and didn’t want to, or think I am just too busy to know better, I’d be grateful if my prescriber took lots of time to share with me that there are great many more pain, sufferings and illness that lays await for me unless I change my ways.

I’d be grateful to the producer, regulator and promoters of medications to direct some of their resources and creative energy to remind my prescriber of the importance patient self-management in the care of diabetes; and that in many cases by following well publicized dietary guidelines the need for medications can be decreased or sometimes eliminated.  Finally, I’d be grateful to the government elected by the people for the people to make it known to me and repeatedly (I think this is necessary to counter the repeated advertisement promoting the more profitable substitutes) remind me that it is foremost my duty as a citizen, a patient, a son, a brother, a father, a teacher and a leader to be be a role model of wellness for everyone around me.

It took some persuasion and negotiation to get Don to join our psychotherapy group; but he eventually came.  He was happy and surprised to meet his grade 5 teacher who was also attending. He told me he had a hard time in school but he can also remembered she was very kind to him.  Don is now 49 years old. Even though he is still on methadone maintenance program, I am grateful for his gradual transformation. During one group, he shared with us his new realization that “addictions” is a common humanity; the only difference is whether one knows it or not.  

Another patient (John) reflected that he now feels a peace that was never possible before.  He used to be afraid to leave the house in the day for the fear that he will become enraged at strangers and cause them bodily harm.  Now John meditates daily with his wife and eats 400 grams of non-starchy vegetables per day. He enjoys great relationships with his wife, daughter and his grandchildren.  He told me he will grow a vegetable garden this spring.

Over the years, he managed to wean himself off opioids, alcohol while on cannabis.  He told me he made cannabutter and baked brownies. He gradually weaned himself off the brownies as well.  Next he quit tobacco. He now manages his chronic back pain without any substance but by addressing his real need for wholefoods, appropriate physical activity, a sense of equanimity with everything (including his back pain), an improved ability to pay attention to what is important and a sense of self-compassion.

For type 2 diabetes, John’s HbA1C was 11.1 on SGLT, DDP4 and metformin in 2016. His last HbA1C was 5.5.  This type results is not uncommon in my patient population. According to a study published in Lancet, “at 12 months, almost half of participants achieved remission to a non-diabetic state and off antidiabetic drugs. Remission of type 2 diabetes is a practical target for primary care”  https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)33102-1/fulltext

Nature of addiction

I read this morning that The Saskatchewan College of Pharmacy Professionals (SCPP) has approved in principle a ban on exempted codeine products (ECPs).

Narcotics (including ECP) are addicting substitute solutions to real unmet needs.  I believe policies, regardless of intention, that bans “substitutes” such as ECP or legalizes cannabis are in themselves “substitute” solutions for the growing issue of addiction in society.  Individuals or governance that are unaware of the nature of addiction will simply switch from one substitute to the next easiest accessible substitute.

My perspective on Cycle of Addiction ( reminiscent of some computer programming language)
Sample program 1: Diabetes type 2 (sugar addiction)

1. Real need: Whole Foods & appropriate physical activity
2. Craving from needs unmet: hunger
3. Easy substitute: simple carbohydrates
4. Brief relieve from hunger
5. Craving recurs from needs unmet: hunger
6. Go to 3.

Sample program 2: Opioid crisis (opioid addiction)

1. Real need: wholefood, appropriate physical activity, ability to pay attention to what is important & self-compassion
2. Craving from needs unmet: pain & suffering
3. Easy substitute: opioids
4. Brief relieve from pain & suffering
5. Craving recurs from needs unmet: pain & suffering
6. Go to 3.

Sample program 3: Workaholism (intentionally left blank. It may be familiar to some readers)

Three challenges of addictions are: 1. Suffering caused by a real need unmet. 2. Side effects of the substitutes.  3. Vulnerability to other harmful substitutes.
I believe much more conversations at an individual and system level about the true nature of addiction are needed.

My conversation with patients about addiction.

I am sometimes asked by patient to prescribe benzodiazepines, cannabis or opioids.

My approach is similar for all medications and substances with potential addiction properties.
1. I explain to them that no one (for emphasis of course, I point out the obvious) including myself is “immune” to addiction; that given the situation, anyone can become addicted. (They usually don’t believe me at this point)
2. I then explain to them the mechanism or cycle of addiction (fear of some suffering/ craving for end of it; seeking a quick relieve / a substitute solution; relieve from suffering; effect of quick solution begin to wear out; triggers the fear of suffer... then the cycle’s intensity compounds); I talk about some real life examples; and there is no lack of stories.  By now, they begin to see how addiction applies to them personally.
3. I then help them understand the lengthy list of other unintended and serious side effects of the substitute solution ( Eg.  Increased risk of falls in seniors; respiratory arrest, quality of life, etc.; I try to use examples most relevant to the individual.
4. I ask them and help them identify what it is their suffering the are hoping to alleviate.
5. I then offer them a real solution to their sufferings.  (Eg. my Basic Wellness Messages)
https://www.whatisharewithpatients.com/2019/02/a-family-physicians-basic-wellness.html?m=1
6. In my experience, above approach has resulted in various satisfactory outcomes; many embrace the knowledge and come to attend my wellness groups and learn more about the Basic Wellness Messages;

some are disappointed but still respect the time spent and reasoning; none leaves with a quick fix or substitute solution without a clear understanding and an agreement on a solid plan to eliminate the substitute with the real solution.

In my opinion, the key ingredient of addiction management are:
1. That I take the time.
2. That I understand addiction is a common humanity. ( remove stigma and judgement of which self-judgement or shame is most intense)
3. That I explain the mechanism of addiction in a way that can be understood by the individual
4. That I help find a real solution to replace a substitute.
5. That a reasonable plan is agreed upon to safely wean off the substitutes and apply the real solution.
6. That I use “physician-led self-management education and support groups” to help patients begin personal transformations.
https://www.whatisharewithpatients.com/2018/12/why-stethescope-and-spinach.html?m=1

I believe we need a system solution that supports more conversations at an individual level.

I see each patient encounter as a valuable opportunity to engage patient in a conversation on the nature of addiction; whether it is to sugar or opioids or anything else for that matter.

I then enrol them in our weekly “physician-led self-management education groups” to continue our journey of awareness and wellness.

I have ran this group for over a year now.  It has proven to be an effective way to help my patients.  

There has been many stories.  John’s story stands out (fiction name).  He has eliminated the substitutes in his life (street drugs, alcohol, cannabis and tobacco) and replaced it with what he truly need (wholefood, appropriate physical activity, improve ability to pay attention to what is important & self-compassion through practice of BAM)

For type 2 diabetes, John’s HbA1C was 11.5 on SGLT, DDP4 and metformin. His last HbA1C was 5.6.  This type results is not uncommon in my patient population. According to a study published in Lancet, “at 12 months, almost half of participants achieved remission to a non-diabetic state and off antidiabetic drugs. Remission of type 2 diabetes is a practical target for primary care”

John meditates daily with his wife and eats 400 grams of non-starchy vegetables per day.  
He enjoys great relationships with his wife, daughter and his grandchildren.  We hope to collaborate and share our perspectives on the importance of vegetables in our diet.

The case of Type 2 diabetes.

According to Shaun Loney, author of “The beautiful bailout - how a social innovations scale-up will solve government’s priciest problems”:

Annual health care cost per Canadian = $6604
Annual health care cost per Canadian with diabetes = $26416
Difference per year = $19812
Even though I don’t have the numbers for opioid crisis, I believe they are also staggering.

It appears to me there is plenty of money to do wonder if we can simply target the real needs rather than direct most of our attention to the substitutes or substitute it with a yet more costly substitute without a clear vision.
https://www.whatisharewithpatients.com/2019/01/a-solution-at-addiction.html?m=1

Disclaimer:
Above are my personal opinions based on my clinical experience.

Awakening: path from addiction to unimaginable beauty

Perhaps the solution to addiction is not to block and let go of everything rather to “awaken” and clearly understand which “needs” is actionable and pay attention.

Memory of past need may be regret or disguised as pride.
Imagined future need may be fear or disguised as hope.
Present need is real.

The Maslow Hierarchy perhaps can be applied to regrets and fears as well as needs.

In autopilot, my brain mingles this matrix of regrets, fear and needs and reacts sub-optimally to situations.
In “awareness”, I see things as they really are, let go of regrets and fears and address only the needs.

In autopilot, there are three level of sufferings:
1. Real needs are unmet while regrets and fear are blocked or escaped from using substitutes or quick fixes. These addictions or behaviour of insatiable craving can be outwardly apparent as in case of overeating or substance abuse or not quite as outwardly apparent in case of perfectionism, workaholism, self-righteousness or being self-absorbed. I think there are many more examples of subtle addictions.
2. Needs unmet and behaviour of using substitutes leads to more regrets (shame) and fear (panic) which propels the infinite loop of addiction.
3. Opportunities to enjoy the vividness of each moments are forever lost.

In “awake-ness”,
1. regrets (shame) are in the past, unchangeable, belongs forever in my memory, informative but does not define me any more than the volume of horror story book sitting on my bookshelf.
2. Fears (panic) are imagined, seems real and becomes intolerable when I pay attention to it and vanishes when I simply redirect attention to the present moment of my breath.  In Harry Potter, Voldemort’s power vanished when Harry accepted and leaned into his paralytic fear.
3. I vividly see things as they really are and responds to the opportunities presented by each moment and meet real needs and experience a life of unbounded, untethered, ungrounded and unimaginable beauty.



To an observer, “awake-ness” looks like:
Dedication,
Performance,
Focus,
Peace,
Pleasantness,
Contentment,
Fun,
Love.

To Jon Kabat-Zinn,

Beginners Mind
Non-Judgement
Acceptance
Non-striving
Letting Go
Gratitude
Generosity
Patience
Trust

To Stephen Covey,

Habit 1: Be Proactive
Habit 2: Begin with the End in Mind
Habit 3: Put First Things First
(Habits 4, 5, and 6 then address interdependence:)
Habit 4: Think Win/Win
Habit 5: Seek First to Understand, Then to Be Understood
Habit 6: Synergize

Addiction is an experience not a personality

Addiction is an experience.  It is the experience of habitually trying in vain to meet a need with substitutes; or grasping to meet an imagined need.  I think when I acknowledge such experiences I am more likely to gain the needed perspectives to see things as they truly are.

Today she came to my office not for herself but to help her sister who just had a newborn and needed to see me.  She told me she is now working as counselor for others who are experiencing problem with addictions.  She shared with me that she can now see how her personal experience with addiction resulted in her compassion for others.  She felt that her work to help others is not merely a job but more a way to be and a way of life.

I don’t think I have all the words to fully express such miracles which I have the privilege to witness and learn from as a family physician.  I do think of my work as not merely a job but a series opportunities to learn and authentically share perspectives with individuals in their moments of need and openness.