Homelessness can be beaten

22 12 2009

In a few weeks, hordes of world’s media will descend on Vancouver, British Columbia for the 2010 Winter Olympic Games. The most intrepid journalists will grab a camera man and head down to Vancouver’s Downtown Eastside (DTES) to get their money-shot: a homeless person sleeping on a heating vent, or a drug user shooting-up in Blood-Alley. Then they will roll out the sad-but-true statistics to contrast the majesty of the snow-capped North Shore mountains with the human misery of Canada’s worst slum. This will be broadcast around the globe for billions to see. There will be gnashing of teeth and wringing of hands, as Canadians are forced to explain the horrors lurking on their doorstep.

However, in the wake of this social catastrophe, there are rays of hope. The local, federal and provincial governments have poured hundreds of millions of dollars into the area over the past decade in an effort to keep this from being cast as a totally bad-news story.

Duncan Sallie, cleaning up

This weekend’s Globe and Mail ran a two page story on Duncan Sallie, an ex-squeegee kid, and his quest for employment on the DTES. Mr. Sallie is a 26 year old homeless man with a checkered past, few marketable skills, years lost to drug-addiction and a history of mental illness. Yet, he showed up to his first job interview wearing a clean shirt and big smile.

One of the stories within the story is the success of BOB (Building Opportunities with Business) a government funded agency which provides unconventional services to the city’s neediest and hardest to employ, resulting in real jobs for 137 inner-city residents, like Duncan Sallie, since October 2008.

Mr. Sallie is an ex-crack addict with a rebellious and violent past. As a child, before taking drugs, he was diagnosed with Attention Deficit Hyperactivity Disorder. Although the story does not specify the details, it is a story that I hear in my office, every day.

Young men like Mr. Sallie have a frighteningly common trajectory. The movie goes something like this…

As a child, he was a charming and energetic boy, who did not like to read and had difficulty sitting still. He was a daredevil, risk taker, good at sports, but bored in school. He may have been raised in a loving home, and may even have done well in school, initially. But his quirks get him rejected by the popular students and invariably he falls in with the wrong crowd. He starts smoking and drinking early. He quickly graduates from smoking to “blazing”, but he does not graduate from high school. Smoking pot starts off as a way to ease the boredom or to be cool, but eventually becomes a daily ritual. If smoking pot is as far as this young man’s drug taking ever goes, the story may be a downer, but it’s not a tragedy.

In order to have a truly tragic ending, he needs to move on to more adventurous experimentation with mushrooms, acid, speed, ecstacy and/or cocaine…. And, he does. Again, while snorting cocaine may leave you in debt, it does not usually leave you homeless. In order to win that distinction, you usually have to tangle with one of the three home-wreckers: crack, alcohol or heroin.

If you want to see homelessness, live and in colour, go down to the DTES. Stand on the corner of Main and Hastings and the sights will break your heart. Homelessness is not caused by lack of money. Every day more money changes hands in the DTES than on the Vancouver Stock Exchange. Homelessness is not caused by mental illness per se. It is caused by the executive dysfunction and impulsivity that is associated with certain types of mental illness including substance abuse and addiction. Can’t get a job; can’t hold a job; can’t pay the rent; go on disability, get housing assistance, but get kicked out for doing drugs or beaking off to the landlord.

Mr. Sallie is trying to change his lot in life. Currently, he is on methadone, prescribed by an addiction specialist in Vancouver. It keeps him away from the needle and allows him to focus on getting a job. But even though 10 doctors will have seen ADHD on his chart at various hospital or clinic admissions, no one will have taken it upon themselves to treat it.

There are some good and practical reasons to be wary of treating ADHD in a person with an active addiction, but the experts agree, it’s not a deal breaker. All the research shows that the risk of treating ADHD, even in the actively addicted, can be managed. The problem is, as in the case of Duncan Sallie, the diagnosis is made and an initial treatment is prescribed, but there are not enough skilled clinicians to provide patient education, follow-up or ongoing treatment for those who go on to manifest ADHD as adults.

There were 1000 adults on the waiting list at the only adult ADHD facility in British Columbia. The BC government wanted to shorten the waiting list, so they closed the program. They pay for the risky, short acting, addictive stimulants, but they do not cover the cost of the safer, non-addictive, slow release stimulants. Go figure. They think they are saving money.

The hallmarks of ADHD are executive dysfunction and impulsivity. A number of recent studies have documented how frequent ADHD is in homeless men. A few years ago, the Mayor of Vancouver, Sam Sullivan tried to start a program of treating cocaine and methamphetamine addiction with “replacement therapy”. It was not a bad idea. If stimulant abusers were addicted to fast-acting stimulants, maybe we could wean them off their drug of choice by using slow-acting stimulants. The same principle is used in replacing heroin addict’s fast-acting opioids with slow-acting opioids (methadone). Sullivan’s wish to get replacement treatment on the street before the Olympics was innovative and plausible with some adjustments, but it met with significant resistance from various stakeholders and the plan died on the vine.

A more rationale idea would have been to screen homeless stimulant abusers for ADHD and, within the risk management guidelines alluded to above, treat their impulsivity and executive dysfunction. Duncan Sallie would likely, in my opinion, have benefitted.

Mr. Sallie showed up to his job interview on time, but at the last minute, he realizes that he has forgotten to put together a resume. He sits down to write one, but he is so nervous and so fidgety, that he spills coffee on his new pants. We don’t know for sure why he does not get the job, but we’re not given any reason to be particularly optimistic.

Last May, I presented a paper at the 2nd International Congress on ADHD in Vienna, Austria. “Management of ADHD in patients with co-morbid cocaine addiction”. To make a long story short, the study which included 53 patients, showed that those cocaine users whose impulsivity was pre-treated with a mood-stabilizer (which inhibits glutamate, increases GABA. or both) before their executive function was treated with ADHD medications, had significantly better outcomes than those who received ADHD treatment without a mood stabilizer. It’s a preliminary study,not yet replicated, and as yet unpublished, but there is a signal there. It is an outcome that I see every day in my practice…

Treat the impulsivity first (by modulating Glutamate and GABA), then treat the executive dysfunction (by boosting Dopamine) and the patient’s function will improve. Here are a few quotes from one the patients in the study….

“I still have ups and downs, but I feel more on an even keel. I can deal with things better. I can listen. I can go to a meeting and actually follow. I can take care of children and really be attentive. It’s amazing”.

“I don’t feel as aggressive. I don’t want to throw stuff, kill people, or kill myself. I’m not as violent. I don’t fly into rages anymore. I don’t seem to have nearly as many cravings. I can concentrate better. I can actually read three chapters. That’s a big improvement.”

I don’t know whether this kind of intervention could have helped Mr. Sallie’s chances of  making a comeback. What is important is that his story has been told and that the people following the Olympics realize that with with the right resources and a little political will, homelessness can be be beaten.

Dr. Anthony Ocana  MSc, MD, CCFP, ABAM             Family Physician/ Addiction Medicine Specialist                 drocana@telus.net


What’s your default mode?

29 11 2009

K2 The Savage Mountain

Last week, an old climbing buddy, Eileen Bistrisky, invited me to a presentation by Canadian climber, Don Bowie. K2 – The Ascent of the Savage MountainI was both inspired and horrified as he described his successful ascent of K2 without the use of supplemental oxygen.. At 28,253ft above sea level, K2, located in Northern Pakistan is the world’s second highest peak. It is widely considered to be the hardest and most dangerous mountain on earth to climb. On July 4th, 2007, Don became the 4th Canadian to summit.

Those are the raw stats. But they don’t begin to describe the strength of character of this young man. Not only did Don and his two team mates make it to the top, shortly after watching a fellow climber slide by and disappear over the edge of a cliff forever. But on the way down, in the falling dark, he stopped to help a fellow climber who had collapsed and was lying motionless in the snow. He could have kept walking. In fact, one got the feeling from hearing the story that the large majority of climbers on that mountain, would have done just that.

While helping that guy down to camp four, Don lost his footing and shot down the icy slope. Maybe it was karma, but it seems it was not his time to die, as he slid feet first into a snow-bank and stopped. 10 feet either was and he would have been toast.

The good news was that he was still alive. The bad news was that his toes on one foot were facing the wrong way; down instead of up – He had badly fractured his ankle. However, when you only have one good leg and you are 24,000 feet up a mountain, you might as well  be dead.

Unbelievably, other than his team-mates, no one else offered him any assistance. Don was stunned. Finally, just before the treacherous ice falls, getting impatient with the lack of empathy, he lashed out in frustration. This seemed to have guilted a few of the otherwise oblivious climbers into action and with that, they carried him through the last stretch. As it turns out. Don, did make it to base camp in one piece and with the help a US Army helicopter, he made it the rest of the way home.

In the ensuing Q and A, someone asked why he was willing to help a fallen comrade when he was surely close to total exhaustion himself. (remember, he has been climbing without oxygen) This is where Don really blew me away…

He said, “I train so that when I’m down to my last 5%, and I’m at the end of my rope, that my default mode is kindness”.

Kindness, now that’s an interesting concept. How many of us are even aware that when push comes to shove, when our brain is being hijacked by pain and fatigue that we even have a default mode? And how many of us have been conscious enough, in that storm of emotions, to be able to step back and pay attention to how we feel, how we are behaving and how we are being perceived? Now, take it one step further…How many of us train to control our behaviour in default mode?

I’m going to suggest that that level of self awareness is pretty rare.

Neurobiologically, we are driven into fight or flight mode when our amygdala, the part of the brain that perceives danger, flips the switch triggering the sympathetic nervous system which responding to the amygdala’s wailing siren, prepares us to either put up our dukes, or get the hell out of Dodge.

On the other hand, when we are down to our last 5%, lactic acid coming from our fatiguing muscles sends an inhibitory signal to our sensory cortex that says, “Batten the hatches, we’re going down”. At that point, parasympathetic functions like consciousness, digestion, cognition and the like start shutting down to conserve energy.

That is why you have to train your default mode.

Because, whatever happens at that point had better be automatic or else it’s not going to happen. So, in fact, not only do you have to have an idea of what you want your default mode to be, but you have to practice putting yourself in that situation over and over in order to train yourself to behave the way you want to in default mode.

In my daily work as an addictionologist, I work with people who are precisely those who in their QuestForFire become completely unconscious of the consequence of their actions Their default mode is to use drugs and alcohol as a way of coping with their dysphoria. I’m not saying that in a pejorative way. It’s just the way it is. That’s the definition of addiction. Continued use of drugs or alcohol as a way of managing distress despite evidence of continuing negative consequences.

So that is why I was so impressed with Don Bowie. In his QuestForFire, his mindset is exactly the polar opposite of impulsivity. In fact, it is the essence of impulse control.

And, when you look at the massive social, economic and interpersonal harm that results when we are unable to adequately control our impulses, you can see the amazing value of Don’s ability to ride the horse, instead of letting the horse ride him.

I for one struggle with my impulse control. It may be in my genes as I come from a long line of short-tempered Spaniards who are known to succumb to temptation. I’m not trying to make excuses. It’s just that I often find myself doing and saying things in default mode that make me shake my head.

“What were you thinking”? I wonder to myself. That’s just it. I wasn’t thinking. I was in default mode. So now the challenge is to imagine a more sensible default mode and to see if I can behave differently enough times to crack the mould and hopefully sculpt something I can be proud of.

Next week we’ll talk more about impulse control, what’s behind it neurobiologically and how we can harness it.

Cheers, A

Dr. Anthony Ocana   MD, MSc, CCFP, ABAM                                                               Family Physician, Addiction Specialist                                                     drocana@telus.net

Everybody makes mistakes.

23 11 2009

Sam Brown

Last week I watched a documentary, on CBC’s The Fifth Estate, on one Sam Brown, a thrill seeking, award-winning, mountain-biker from Nelson BC, who found the greatest thrill was hauling hockey bags full of pot across the border to the US. (http://www.cbc.ca/fifth/2009-2010/over_the_edge/)

Sam didn’t fancy himself a drug dealer and would be offended at the suggestion. In his mind, he was just having fun. The more dangerous the mission the better. He revelled in pushing the limits and fancied himself as quite the tactician. And as time went on, the rewards got bigger.

Sam surrounded himself with fancy bikes, fancy sleds and fancy girls.

But the risks got bigger too. Soon enough, Sam was not only dropping off pot, but hauling back coke on the return trip, hundreds of kilos worth.

Even his Dad figured something was up when Sam came home one night with a helicopter for his Dad to fix. You’d think Dad would say something like, ‘What the hell are you doing with a helicopter. Are you out of your frickin’ mind. Do you know what the American’s will with you if they catch you? But instead his attitude was, ‘Don’t ask, don’t tell’. “I’d rather aid and abet my son’s illegal activity, than watch him crash because of faulty equipment”.

As it happens, one of Sam’s associates found herself with faulty equipment caught in the wrong place at the wrong time by the Feds and doing time, awaiting trial in the US. With the heat on, Sam starts wondering whether maybe he should quit while he’s ahead. Plan B was to cash out and maybe find something a little more mainstream. But, of course, there would have to be one last run to raise money for his associates’ legal fees.

As it happens, the DEA was on his tail too… and on that fateful night, with darkness falling and wind and snow closing in on him, he flew right into the web that his captors had set for him. Long story short, when they stuck this young man in the local jail, his characteristic bravado nowhere to be found, he hung himself with a bed-sheet.

Lyndon Mackintyre who I have always found to be an excellent journalist ends the piece with a sob-story about how this is his handler’s fault, the American’s fault, the drug culture’s fault, his parent’s fault. Everyone is to blame, except Sam. I nearly threw up.

But then I though, maybe I’m being a little too judgmental. So, I’m exploring the topic today in QuestForFire because it brings up a number of issues that I think are at the heart of our societies current ambivalence towards addicts and addiction.

My sense is that people are drawn towards one side or the other based on their inherent empathy quotient.

On the one side, those who do not fell for Sam, see him as the master of his own fate and as awful as it may seem, shed no tears for the daredevil drug dealer. This is the side to which, I must say, I gravitate to, at least initially. It’s not so much that I have no empathy for him, but rather that I have more empathy for the drug users who end up homeless, psychotic or in a ditch somewhere, as a result of the crack, that Sam was able to supply them with. As an addiction specialist, I am only too familiar with the shattered lives that drugs (and alcohol) leave in their wake.

On the other side, are people with a high empathy quotient who feel sorry for Sam and his family. They see Sam the victim, the young man with poor judgement. “Everybody makes mistakes”, they say.

Sure, everybody makes mistakes. But this was not an act of impulse. This was a repeated and persistent pattern of willful anti-social behaviour.  Sam was happy to enjoy the fruits of his labour and even took umbrage at being labelled a trafficker. But that’s what he did without any thought of the consequences to himself or to others.

Some have said, he was just looking out for number one. And if he didn’t deliver those drugs, well someone else would. And that’s true. But it doesn’t change the fact that it was wrong, and he knew it.

But there is another way of looking at it… that was not raised in that very long list of viewer feedback on the CBC website. Sam Brown was a daredevil, a thrill seeker, an adrenaline junkie. He had to to push the limits, because doing what everyone else does, the way everyone else does it, is just too boring. I know the type. I work with them every day. As an addictionologist, understanding this, is my stock in trade. Maybe Sam Brown was just a different kind of addict.

There is quite a bit of science that says that Sam Brown was likely suffering from Attention Deficit Hyperactivity Disorder. He has all the hallmarks: He was smart, but did not do well in school. He was hyperactive, never could sit still. And he was impulsive, to the nth degree. About 50% of ADDers suffer from one or more addictions (if you include nicotine) and probably higher if you include behavioural addictions such as compulsive shopping, gambling, gaming, sex and eating.

Addiction and ADHD have a lot in common. They are both associated with dysfunctional dopamine circuits. (read more about it on my web-site, northshoreadhd.com. I won’t go into anymore detail on that, but suffice it to say, both addicts and ADDers have chemical imbalances that lead them to be easily bored, to be unlikely to learn from their mistakes, and to have difficulty saying, “no” to temptation. And that leads them to make exceptionally bad choices, and to have the kind of poor judgement that can kill you.

So, I guess, if I think about it, maybe I can find some empathy in my heart for Sam Brown. I certainly feel for those who lost a friend or a family-member.

As a physician, hearing a story like this I find myself wondering, “what if”. What if someone had seen the ADHD pattern and directed him to some treatment. Or what if he had been able to stick to a less dysfunctional addiction such as extreme mountainbiking.It would have been nice to have been able to help this young man before he felt so desperate that he ended up taking his own life. I now if he were my patient, I might be able to look past his poor judgement. As long as he/she were willing to take some ownership of their actions. Those with a higher empathy quotient might say, “Let he/she who has not made mistakes, cast the first stone”.

Cheers, A

Dr. Anthony Ocana   MD, MSc, CCFP, ABAM                                                   Family Physician, Addiction Specialist                                         drocana@telus.net


17 11 2009

QuestForFire is my new blog. I am an addiction specialist and would like to share some thoughts with you…LIfe through the lens of neurobiology. My teachers are my patients. They are like snowflakes, no two are completely alike. I feel honoured to work with them and not a single day goes by that I don’t learn something new. I’m sure I learn more from them than they learn from me.

Addiction refers to those experiences that are so engaging that once we taste them, we become so enthralled that we quickly find ourselves planning our next visit to this wonderful place. If we are not careful and if we are vulnerable to addiction we soon find ourselves seeking to recreate that initial high, not withstanding the harm that this might cause us, or those around us.

Addicts continue to use their “drug of choice”, despite negative consequences.

Before there were drugs, there were likely other pinnacle experiences that our ancestors had, and sought to repeat. I imagine that one of these occured the first time they tasted glucose from a sweet overripe fruit, first time they mated, or the first time they were able to harness fire.

I imagine that after any of these experiences, they were probably so excited that nothing else mattered. In fact, they may very well have forgotten to eat or sleep for days when they were right down to it. That sort of engagement, while not dysfunctional per se, is the kind of intense focus that accompanies the first hit of any highly pleasurable substance/ behaviour. So that’s why I’m calling this blog about addiction, “QuestForFire“.

Cheers, A

Dr. Anthony Ocana   MD, MSc, CCFP, ABAM                                                   Family Physician, Addiction Specialist                                         drocana@telus.net