I wonder how much cannabis manufacturers pay patient advocacy groups and professional societies

I also wonder how much cannabis manufacturers pay patient advocacy groups and professional societies that have great influences on policies, guidelines, medical education and our culture.
The education on the medicinal use of cannabis is mostly funded directly or indirectly by the producers.
I read in Wikipedia, “..in vitro studies indicate CBD may interact with different biological targets, including cannabinoid receptors and other neurotransmitter receptors, as of 2018 the mechanism of action for its biological effects has not been determined...It is an allosteric modulator of the μ- and δ-opioid receptors as well.”   
While I have no clue how CBD actually works, it  being both a potent psychotropic and analgesic suggests to me of it’s potentially a dangerous substitute or quick fix solution for dealing with pain and suffering.
While I suspect there must be research on CBD safety and benefits eagerly and earnestly shared by producers and promoters; I am hesitant to abandon all caution.  I read not all that long ago Valium was promoted as safe and a way to safeguard the virtues of college girls who might otherwise succumb to crumbling moral standards.  More recently oxycodone was prophetically promoted as the “one to start with and the one to stay with”.

Three challenges of “quick fixes” or 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.

I think in general, pain, suffering and illness are consequences of being alive, of having the freedom to choose between what’s good for me and what is bad.  They are teachers constantly reminding me of what my body needs and what my mind don’t. A “health care system” that narcotizes me and leaves me benighted of the consequences of my poor choices would only leave me insatiably dependent on it.

Hippocrates said “Before you heal someone, ask him if he's willing to give up the things that make him sick.”

I think, voicing problems without making any personal efforts towards potential solutions makes little sense.  Someone also said “you are either the solution or the precipitate”.

So my personal solution to this challenge, at least for now, is to continue to learn from my pains, sufferings and illnesses to let go of what my mind wants and make tough moment by moment choices that are good for the body, the community and the planet; and to share my perspectives at every opportunity and clinical encounters.

What about legalization of cannabis?

What I see lacking in the process of legalization of cannabis is any substantial public campaign to educate the public on the harm of the non-medical and medical use of cannabis.
As in the case of most medications, the promotion of and education on the medicinal use of cannabis is mostly funded directly or indirectly by the producers.

I read in Wikipedia, “..in vitro studies indicate CBD may interact with different biological targets, including cannabinoid receptors and other neurotransmitter receptors,[9][12]as of 2018 the mechanism of action for its biological effects has not been determined...It is an allosteric modulator of the μ- and δ-opioid receptors as well.”   

While I have no clue how CBD actually works, it  being both psychotropic and analgesic means it is a potential substitute or quick fix solution for dealing with pain and suffering.

My approach is similar for all medications and substances with potential addiction properties.
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)
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.
I begin with discussion to help them discover the root of their pain and sufferings.  I then help them understand the lengthy list of unintended and serious side effects of the substitute solution ( Eg.  Increased risk of falls in seniors on psychotropics; respiratory arrest on opioids and benzodiazepines, cannabinoid hyperemesis syndrome, worsening anxiety or onset of psychosis associated with chronic use of cannabis, etc.)  I try to use examples most relevant to the individual.
I ask them and help them identify what is the suffering they are hoping to alleviate.
I then offer them a real solution to their sufferings.  (Eg. A Basic Wellness Messages)
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.

One young man asked me for lorazepam to help him sleep.  He had been suffering panic attacks and had not slept much for 6 nights.  He managed to struggle through each night using the Breath Awareness Meditation I had taught him.  He said he was able to sleep last using the lorazepam his mom gave him. He said her mom wants me to give him a prescription for the same.  I reminded him about his experience with Cannabis. About a year ago, he disregarded my warning that cannabis will likely worsen his anxiety and had persisted on using cannabis to deal with anxiety.  He finally did stop using cannabis as his panic attack did increase and were associated with frightening attacks of globus. On his last visit to me he was deeply grateful for being able to finally quit cannabis using BAM.  He said the globus was so frightening that he will never touch cannabis again.

I then told him the use of lorazepam as a substitute solution will only worsen his problem with panic attacks.  I also told him that if I give him lorazepam I would have nullified his 6 nights of valiant struggle that prevailed using BAM.  I reassured him that if he is no worse for wear after 6 nights of panic attacks; he will be just fine again. I reminded him how much stronger he had become.  I reminded him of his success overcoming his dependence on cannabis. I reminded him to try leaning into his discomfort and welcome the experience with acceptance and equanimity.  He finally told me hesitantly that he will trust me and give it a try and overcome his anxiety using BAM.

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.

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

I struggle to understand...

I struggle to understand the strong presence of marijuana producers at Family Medicine Forum.
I don’t pretend to know all the answer but suspect the following:
1. They paid someone to be present.
2. They hope to make that money back and then some by being present.

The implicit messages to our student and physician membership may be that:
They can be counted to provide fair and unbiased information. (In contrast to say tobacco or alcohol producers)
They are producing a sufficiently “safe” product and their strong presence at FMF do not need to be balanced with an equal representation from those who believe marijuana may be a public health hazard.

I also struggle to understand the breakfast choices of simple carbs at FMF for ~6000 of my esteemed fellow family physicians and leaders of wellness.

Again I have no certainty but suspect:

A breakfast in line with Canada Food Guide 2019 cost more and the FMF fee needed to be allocated to a more important function and was insufficient.

The implicit messages to our student and physician membership may be that:

1. Healthy breakfast is important but there are more important matters.
2. Healthy nutrition may prevent and improve chronic physical and mental conditions for patients and physicians alike but family physicians do not have to be a good role model; may eat poorly when there are more important things to do such as learning how to treat diseases caused largely by eating poorly.

I think there are many object of human addictions; but two prominent examples are to sugar and to narcotics.

My perspective on Cycle of Addiction

Sugar addiction:  Diabetes Type 2 Epidemic (30% of Ontarians are diabetic or prediabetic in 2016)

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.

I struggle to understand why in this days of Type 2 diabetes epidemic, such glucose beverages or a simple carbohydrate breakfasts still remain so popular;  and why as a society we don’t seem to be all that alarmed? We focus on treating A1C to target with medications to prevent organ damage; we provide even more phenomenal and technologically advanced care once the kidney fails; but seem so bored with issue of self-management that has the potential to prevent diabetes and potentially save the system $19500 per year per person ( times 3.9 million Ontarians).

Opioid addiction: Opioid Crisis (9000 opioid related death in Canada since 2016; 2066 apparent opioid death in 2018; most death in 30ish year olds; 17 people hospitalized for opioid poisonings in Canada each day  2017)

1. Real need: wholefood, appropriate physical activity, understanding role of pain and suffering, ability to pay attention to what is truly important and 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.

Where does marijuana fit in for most users?  My present (please correct me if I am wrong) thinking is that absorbing it daily is not a true need like being nourished by 400 grams of non-starchy vegetables daily.

While I suspect there must be some studies by now demonstrating its safety and benefits eagerly and earnestly shared by producers of such a profitable product; I am hesitant to abandon all caution.  I read not all that long ago Valium was promoted as safe and a way to safeguard the virtues of college girls who might otherwise succumb to crumbling moral standards. More recently oxycodone was prophetically promoted as the “one to start with and the one to stay with”.

Certain glucose infused beverage also contained cocaine in the past; now it’s just effectively promoted as “the real thing”.

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 the capacity and power of “self-management groups” to help patients begin personal transformations.

Thank you for reading!

Tribute to our children who survived the Death Squad of El Salvador but did not survive the Canadian Opioid Crisis

A while ago, a good friend shared with me his story.  Shortly after arriving in Canada as a teen refugee from El Salvador, he along with a group of “new arrivals” were invited to a party.  At the party, they were all given the “choice” to snort lines from a table covered with cocaine. He politely declined and left with his little sister.  He said other than him and his sister, everyone in that original group of “new arrivals” have since died.

I know banning cocaine did not save his young friends.  I suspect legalizing cocaine would not have helped. I somehow also suspect a governance similar to Bill 2 would have been also futile.  

I believe giving individuals the “choice” to use cannabis without providing the knowledge of the nature of addiction represent not freedom but enslavement.  

I believe age is an inadequate predictor of awareness and understanding. The opioid crisis does not seem to spare individuals past their teens.

These rules and policies all seem to be a substitute for a real need.  A need for authenticity. A need to have conversations about addiction that brings more awareness.

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

My approach is similar for all medications and substances with potential addiction properties.

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)

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.

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.

I ask them and help them identify what is the suffering they are hoping to alleviate.

I then offer them a real solution to their sufferings.  (Eg. A Basic Wellness Messages)

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:

That I take the time.

That I understand addiction is a common humanity. ( remove stigma and judgement of which self-judgement or shame is most intense)

That I explain the mechanism of addiction in a way that can be understood by the individual

That I help find a real solution to replace a substitute.

That a reasonable plan is agreed upon to safely wean off the substitutes and apply the real solution.

That I use “physician-led self-management education and support groups” to help patients begin personal transformations.

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

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.