Unintended Consequences and the Perfidy of Human Behaviour

By Dr. David laing Dawson

The scourge of drug addiction and premature death from drug addiction has always been with us in some form or other. And over the past 20 years, in this part of the world, and many other enlightened jurisdictions, we have tried very hard to reduce the harm caused by drug addiction.

• We have redefined addiction, at least in part, as an illness rather than a choice, to some extent absolving the sufferer from any personal and moral responsibility.
• We have ensured medical doctors do not contribute to addiction by prescribing excess opioids for pain.
• We have institutionally aligned drug addiction with mental health and mental illness services.
• And we here and there have provided safe injection sites, methadone clinics, and ubiquitous Naloxone kits. We have, in theory, made it much safer to use and to survive an accidental overdose, and much easier to get into “treatment”.
• Insite opened in 2003 as North America’s first legal supervised injection site, located in Vancouver’s downtown eastside. Their published statistics have been quite remarkable, showing the number of customers per month, the few overdoses on premises, and the fact of no deaths occurring on premises.
• And of course we have made marijuana legal in Canada.

But, in British Columbia and throughout Canada, the number of deaths from accidental overdose has (with one year exception) increased year over year the past 20 years, peaking, so far, for British Columbia, with 201 deaths in the month of October, 2021, and 1782 for the first ten months of 2021.

Of course, well-intentioned people are now calling for more safe injection sites, more treatment facilities, more money spent, more de-stigmatization, more empathy, and no legal ramifications for holding small amounts of illegal drugs.

(As a side note I think institutionally aligning drug addiction with “mental health” did not help the addicted population much, but certainly increased the stigma of mental illness. In fact, in public attitude, it has, in a sense, tarred mental illness with the same brush as addiction. In our folk wisdom we know, really, that there is at least some choice and personal responsibility involved when someone reaches for that needle or packet of powder. And now, I suspect, at least more than in the period between 1960 and 1990, our folk wisdom (mixing addiction and mental illness in our minds) has allowed us to assign some personal responsibility and choice (blame) to the homeless person suffering from schizophrenia.)

I don’t profess to have an answer, and I know there are other variables afoot, COVID being one of them, but I think before we insist on doing more of the same, more safe injection sites, more addiction treatment, more naloxone kits, more de-stigmatizing of addiction, legalizing all drugs, we should seriously consider that what we have done for addiction over the past 20 years may have made the problem worse; and it certainly did not reduce the numbers and it certainly did not help attitudes toward mental illness.

(I just read an article from some authority claiming we must do something different for addiction, but then went on to propose more of the same.)

But here is an idea: 2000 overdose deaths in one province in one year is a big cohort. Why don’t we study each and every one of these overdose deaths in depth to look for some clusters or patterns. And if we find some patterns or identifiable clusters we can then develop some targeted prevention, rather than argue about large grand schemes (that could have more unintended consequences) such as legalizing all drugs, or providing safe injection sites in every neighbourhood.

The basic demographic data is available: male, female, age, drug found in the system, but many more questions could be asked, such as:

How many were taking prescription opioids safely before being cut off?

How many of these deaths have occurred because of a contaminated supply?

How many of these addicts had an underlying and treatable mental illness?

How many had underlying other medical conditions or deficiencies?

How many of these overdose deaths are occurring in back alleys and how many in homes or housing of some sort?

How many of these deaths are addicts using alone?

How many of these overdose deaths are occurring with addicts who have gone through treatment programs and have had a period of being clean and thus developed reduced tolerance and then gone back to using the same dose as before?

For how many was addiction a replacement for meaningful activity or a replacement for meaningful human relationships?

(Most accidental-death-by-overdose cases I read about, including that of famous musicians and actors, have been situations of a period of sobriety by choice or force (jail, hospitalization, treatment program) followed by a relapse. If this is a significant percent of the death by overdose population it suggests a very inexpensive and targeted prevention program would include clearly telling every addict as he or she leaves a treatment program, hospital or jail: “You will relapse. And when you do you must cut your usual dose in half or you will die”.)

I Hate Science.

By Dr David Laing Dawson

Or, at least I recently developed some empathy for the anti-vax, anti-science crowd.

I watched a video of Dr. John Campbell (who seems quite sane, balanced, knowledgeable) in which he promoted high intake of vitamin D as a way to prevent severe illness and death from COVID, based on two German studies. It all sounded quite reasonable; the data seemed to speak for ?themself.

That evening we were going to be spending some time with my son and his family and I made a mental note to myself to persuade them to increase their Vitamin D supplements.

But later in the day, I thought I should look more closely at this recommendation before bringing up the topic, in order to maintain my reputation with my son.

So I spent some time looking at other studies, some meta analyses and attempts to replicate the German data, and, of course, it all washed out, inconclusive, not so clear cut, beyond some support for the idea that if you are actually Vitamin D deficient you are more vulnerable.

And therein lies the difficulty with science in matters human, human health, illness, suffering. Variables, biases, expectations, wishful thinking, cognitive dissonance, the Hawthorne effect, the placebo effect, the effect of social pressure on perception, the corrosive effect of money, the power of context, and the fact that our emotional system almost always wins when it goes mano a mano with our cognitive processes. To say nothing of how much we humans love the simple convenient answer. He’s a Taurus; that explains it.

Wouldn’t it be nice if a little bit of surgery on a vein cured MS? Or megavitamins cured schizophrenia? Or some tea made from a rare plant starting with the letter X cured cancer? Or doubling up my dose of Vitamin D and adding a little zinc, plus a good mouth wash, protected me from COVID?

Unfortunately in matters of health and science we can’t trust our own eyes and ears and the experiments to prove something or disprove something in any conclusive way can be very costly, must be double blind, eliminate every conceivable other variable, have a sufficiently large cohort and be replicated somewhere else by someone else.

What a bother. No wonder we are so apt to say, “My neighbour swears by it and that’s good enough for me.”

So I will not double up my Vitamin D supplement but I will continue to take about 2000 IU each day, because, and there is plenty of science behind this, I am only getting about one half hour of sun exposure per month these days.

Omicron, be gone.

Seasons greetings to all

Anti-Vax Docs

By Dr. David Laing Dawson

Yesterday in British Columbia three (3) doctors, M.D’s, spoke at an Anti-vaccination rally. Each mouthed a fair amount of nonsense along with being simply against COVID vaccination. One even promoted Ivermectin.

As medical doctors I assume they attended University for 3 or 4 years before entering medical school, and I assume they graduated after 4 more years of University and interned. And I must assume that along the way they learned a little of the history of modern medicine and science, and of diseases and historic epidemics, from the Bubonic Plague to Cholera to the Spanish Flu.

So what is astonishing to me is that they are opposing the one achievement of modern scientific medicine that towers above all the others: vaccination. There are very few other medical discoveries and practices that have had world-wide positive effect (positive with the exception of contributing to the population explosion, that is). The other impressive achievements of that magnitude that I can think of off hand might include the public health measures for potable water and sewage disposal, along with antibiotics, prenatal and post-natal care, insulin, and anti-psychotic medication.

But vaccination towers above all of these in the numbers of lives saved or spared, in its dramatic impact on the centuries old scourge of infectious disease, on death in childhood or in the act of giving birth.

The rest of modern medicine mostly prolongs the lives and reduces the suffering of many people in the developed world, long past the age of reproduction.

There is much room for disagreement and argument in modern medicine: routine mammography, routine physical examination, over use of antibiotics, over use of many drugs pushed by big pharma, arthroscopy, percentage of births by Caesarian, addictions vs. treatment for pain, taking pills for stress or sadness, best diets, exercise, Viagara for dementia, vitamin supplements, coffee or tea……….

And it is reasonable to distrust big Pharma, or any big corporation for that matter.

But here we are, after a hundred years of vaccinations eliminating or almost eliminating many infectious scourges, from small pox to diphtheria to polio, facing, as of the final months of 2021, a new and constantly mutating virus and the fourth or fifth wave of a pandemic that has now killed 800,000 Americans and 30,000 Canadians, along with the incredible development and testing of vaccines within a year of the start of this pandemic, with more data being accumulated and made public about the efficacy and safety of these vaccines than any other treatment or prevention ever offered by any health care provider, and we still have some doctors opposed to vaccination.

Perhaps we could have guessed there would be quite a few “vaccine hesitant” citizens and predicted where most of them would reside, what level of education they had achieved, and of what political party they favoured, but never would I have guessed we would have actual Canadian medical doctors publicly opposing vaccination.

Note to the College of Physicians and Surgeons: Action is needed now.

Guns and Teens

By Dr. David Laing Dawson

As either a parent or a law maker, a clinical case from some years ago tells you all you need to know about teenagers and guns. I will have to leave out some details to keep this anonymous.

The boy had a girlfriend. He and his dad hunted together. The father kept his rifles in a locked cabinet. Some jealousies and betrayals occurred in the girl/boy relationship. Someone posted salacious accusations against the boy on social media.

The boy decided his life was thus ruined, permanently and forever.

He decided he would have to kill himself.

That night he broke into his father’s gun cabinet and took out a rifle. He found the ammunition, loaded the rifle and took it into the back yard. His parents were upstairs asleep.

The boy sat beneath a tree, placed the gun between his legs, the muzzle under his chin. He fired the rifle. The bullet tore through his jaw and mouth and nose and ruined his face. But it missed his brain.

Damaged and bleeding he found his way back to the basement rec room and the gun cabinet. He then replaced the rifle and locked the cabinet because at that moment his worse fear was of his father finding out he had broken into the gun cabinet. He then lay on the floor where his mother, wakened by the gunshot, found him.

He survived.

I was thinking about this case because of the current tragedy in Oxford Michigan. Definitely it is a rather extreme situation when a parent buys an automatic handgun as a Christmas present for a 15 year old, and then stores it in a bedside table; and this child writing “the thoughts won’t stop. Help me” does indicate the possibility of a psychotic illness developing.

But going back to the situation above:

• This otherwise bright successful teenager suffers social embarrassment/shame at school, in his peer group. (This is bound to happen at some time for many if not most teens, and greatly magnified these days by social media)
• From this he concludes his life is over. (Of course, he has no sense of time and perspective as a teenager)
• He decides the only path is suicide in dramatic fashion. (As a teenager, thinking through alternatives to direct action is beyond his capabilities, and as a teen he has no real sense of how permanent and devastating to family that action could be and/or he might even, before the age of 18 or so, imagine being around to see the consequences of his actions on the friends who betrayed him. A “They will be sorry” moment.)
• He doesn’t tell his parents because of his sense of shame, his need to present himself to them as an adult, a “man”, and not a frightened child. Though given enough time, most parents would notice something is going on with their child.
• Of course he knows how to get into the gun cabinet. Or his mother’s purse, his father’s wallet, the liquor cabinet, the porn sites on his computer, the basement window. It is an adolescent prime directive to figure out how to get around the rules.
• And then the most telling and yet hopeful bit of all: after shooting himself and ruining his face he is still most concerned about getting caught breaking into the gun cabinet and incurring his father’s disappointment and wrath. So he puts the gun back before lying on the floor to die.

Average teenager, ordinary parents, suburban middle class, a moment of social shame, embarrassment among peers, an extreme adolescent reaction to this, and ….. an available gun.

It’s Time to Call Schizophrenia Early Onset Alzheimer’s

By Marvin Ross

OK maybe I’m being a bit facetious but I do think it is very revealing to compare how the two groups of people are treated and particularly as there are similarities in the two diseases. I first wrote about this in Huffington Post about 10 years ago and I’ve used the line that we do not let granny live in a cardboard box in an alley somewhere so why do we do that with those who suffer from schizophrenia.

What I said in 2011 was “Alzheimer’s disease impacts the elderly while schizophrenia, which begins in late adolescence, initially impacts the young. Among the symptoms of Alzheimer’s are delusions, paranoia and impulsive behaviour. Symptoms of schizophrenia include hallucinations, delusions, thought disorder and, in many cases, paranoia.” In a recent podcast interview (see below) I mentioned that when schizophrenia was first described by Arnold Pick at Charles University in Prague, it was called dementia praecox or premature dementia. The term was popularized by Emile Kraepelin.

What has solidified my view on this is that I am the power of attorney for someone with Alzheimer’s and so I can compare his treatment to that of my relative with schizophrenia.

My friend has been living in a dementia care residence for people with mild to moderate impairment but with the understanding that he will worsen and require nursing home care. Despite a doctoral degree and a successful writing career, he has no insight. He denies he has Alzheimer’s preferring to say that he is simply eccentric. Getting him to move into the residence took the efforts of relatives who flew here from the UK and the US.

He is now at the point to need heavy duty nursing care and when I spoke to the co-ordinator who arranges nursing home care, she wanted to talk to him to get his permission to put in an application. Sounds a bit familiar to those of us dealing with family with schizophrenia and anasognosia. But there was a difference!

When I explained the situation and the lack of insight, I was told that she would go to see him and do a competence assessment. She got back to me with “he is not competent”, and so I am allowed to make the decisions as power of attorney. How totally different from psychiatry. But an even bigger difference is the absence of a rights adviser as we have in Ontario for psychiatric patients. The Psychiatric Patient Advocacy Office or PPAO visits all patients declared incompetent and lets them know they can appeal that designation. They can even get a lawyer free to represent them while they delay any treatment that is required.

I’m not suggesting that people’s rights not be protected but people do have the right to be well and the right to be freed from the chains of their psychosis and that does not happen when lawyers get involved and fight with doctors and the families. One of the most upsetting cases I wrote about concerned a woman on a community treatment order living in a group home. Her status was up for review and she appeared with a lawyer well known for opposing treatment orders. Due to a clerical error, her family were not notified of the hearing and the board rescinded the treatment order.

The woman disappeared and could not be found anywhere. As she had no cell phone or credit cards, it was difficult to find her and police were convinced she was dead. Months later, she was found in a homeless shelter in another city about 50 miles away but the story could have had a totally different outcome. having interviewed the missing woman’s family, I have an inkling of the pain they went through fearing for the worst. None of it should have happened.

Going back to my Alzheimer’s friend, he became ill and is now in the hospital and I am again astounded by the differences between his stay and that of someone with schizophrenia. Hospital staff are quite open to talking to me and giving me progress reports. At one point, I mentioned the problem of the demented elderly blocking beds in acute care hospitals because there was nowhere to send them as we do not have sufficient long term nursing beds. The doctor assured me that he would stay in hospital as long as it was needed so he could improve as much as he is capable of improving. Contrast that with psychiatric units that can’t wait to kick patients out before they are properly stabilized.

This week, we had a conference on his future care involving hospital staff, the dementia care home staff, his regular doctor, the social worker from that office and the case co-ordinator arranging long term care. We have a solid plan moving forward. How often does that happen in schizophrenia? A large comprehensive meeting only happened once at the outset of the diagnosis of my relative but no plans were formulated. We were told we might want to learn as much as we could about schizophrenia and when I said maybe the hospital should have some material for families, I was told they did not.

Aside from that first time and another occasion when the psychiatrist categorically refused to talk to family, most of my experiences with psychiatric units have been fairly positive but not always. At one point, my family member was moved to a different unit twice without my being told. When I called the unit on each occasion, I was told they had no patient by that name there and when I asked where he was, I was told they could not tell me. It was easy enough to find out. All I had to do was call the switchboard and ask for patient information. I was told where he was.

I then had to call the charge nurse on duty to force the unit staff to talk to me. All staff involved including the psychiatrist who refused to talk to me were disciplined by the hospital administration and a record of that was put into their personnel files but no one should have to contend with that level of stupidity. As one sensible psychiatrist once said to us, when the family is involved the outcomes are much more positive. He added that it bothered him to have patients with no family involvement as the outcomes are not as satisfactory.

If health care staff can act sensibly with dementia patients they can and should do so for those with serious mental illnesses. We should not expect less.

Guest Blog – F*** All in Common

By Erin Hawkes-Emiru Author of When Quietness Came A Neuroscintist’s Personal Journey with Schizophrenia and When Neurons Tell Stories A Layman’s Guide to the Neuroscience of Mental Illness and Health

My first client as a peer support worker was angry with his assigned mental health and addictions team. I, timid by nature, was overwhelmed. I could certainly identify with his anger at the mental health system, including involuntary hospitalizations, forced injections, and being tied in restraints – these experiences I too had undergone. But the extreme poverty, the history of repeated homelessness, the reliance on “dumpster diving” for food and possessions, the persistent physical pain of arthritis, and the addiction to crystal meth? I had and have a very privileged and comfortable life, despite my mental health issues. How could I say the peer support line of “I know” to him? I couldn’t.

So I listened. To story after story, I listened. For hours, every week, over coffee. Somewhere along the line, his anger faded from our visits, and the stories became more personal, more vulnerable. He asked me a bit about my life, and I shared a bit. Enough for him, one day, to say very accurately to me:

“We have f*** all in common.”

I nodded.

“… but you’re my best friend.”

I looked at him, held his gaze. Somehow, by saying little and listening abundantly, empathy had been communicated. The chasm of f*** all in common had been bridged.

*******

This client’s experiences appear in Neurons Telling Stories; “Miguel” even wrote the poetry that appears as a preface and a photo of him graces the cover. He knew this, having signed the releases. He was excited to see this all, real, in print.

Then I found a dime. It was on a Tuesday, and I, on maternity leave, was walking home from a local park with my husband and toddler daughter. I glimpsed a dime on our path, and stooped to pick it up. “Oh,” I said to my husband. “One of my clients told me that when you find a dime, it’s someone who has died saying hello.” I pocketed the dime.

The next day, Wednesday, I was told that on Sunday, Miguel had died. Overdose.

That dime I keep with me, now taped to a card in my wallet. It reminds me of the power of listening, when empathy involves going from “What’s wrong with you?” to “What happened to you?” At Miguel’s memorial, I realized that I had truly been the closest person to him in these past few years. We had spent over 700 hours together, as he was fond of counting.

*******

Then, I wrote about neuroscience? About how our brains can, like any other organ in our body, malfunction? Doesn’t that go back to “What’s wrong with you?” Often, yes. But I think that when we learn about the role of, say, the insula, or the workings of oxytocin, it provokes empathy: our brains are vastly more similar than different.

Empathy is saying “I know” when that is true, and is shutting up and listening when it’s not. It’s how we bridge from “f*** all in common” to “best friend.” Best friend? Peer support work is not about friendship, at least not in the usual sense of the word. But sometimes friend is the closest word to describe the empathy expressed and received. When our life histories are miles apart, we rely on the “What happened?” and that keeps us humble, quiet, and without judgment.

When Neurons Tell Stories was born of such. My MSc in Neuroscience continuously makes me wonder at how and why neuroanatomy and neurochemistry matter when you are living, as I and my clients do, with a mental illness. No story can be told without the work of billions of neurons, and no neuron can activate without cascading up to some part of a life story. Empathy is not just possible; it becomes expected whether we trace the neurons’ activity in a lab or listen to life histories in a downtown, run-down hotel room. And with empathy, we can change lives, both those of others and our own.

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This is Erin’s full interview about her book