The Future of a Planet on Opioids: Who Guards the Guardians?

Recently I’ve been reading about the reported meteoric rise across Western nations in the prevalence and incidence of non-prescription drug use and trafficking, human trafficking, and the similar stats about arrests for alcohol addiction. Distinct from but related to these dire trends, are the overarching prevailing factors of climate change and pollution. I will treat those latter two topics in a later post.

My focus here is on the whys, whos, and hows of physical and mental abuse from drugs and alcohol overuse. 

Opioids and crystal-meth are the street drugs of choice for most junkies today, and alcohol continues as well to shatter the lives of its victims. That is the chemical tapestry upon which thousands upon thousands of lives each year are ensnared by addiction and snuffed-out by overdosing. A recent drug bust here in Thunder Bay, Ontario, netted the police over $275,000 in drugs, including cocaine, $100,000 in cash, and 1,000 fake pills actually made of fentanyl. Street gangs from Southern Ontario were in town selling mostly to northern reserves. Addicts also are reported missing just about every week, or found dead in town at the rate of 1-2 per month. And that’s only one city in Canada.

The reasons for taking illicit drugs are many and varied, but the majority are traced to;

  • high unemployment
  • a culture of poverty and school drop-out
  • domestic violence
  • easy access to drugs
  • a fatalistic view of life

Vulnerable people are the victims and targets of the drug trade. Their ages range mostly from mid-teens to late 30s. 60% are male; 40% are female. Many have children of their own. Many are homeless, in a shelter, or living in the downtown cores with 3-4 people per dwelling (room or apartment). Many are treated in hospital for addiction, anxiety, and psychosis. Some are treated or counseled through community support organizations but many of those treated are repeat offenders. Some end up in jail from inflicting violence on others.

This situational summary is not new. These issues have been around for decades in cities across the country, but the point is that the incidences have increased over the past decade at an alarming rate. Local police do not have the resources to be effective in controlling this social corruption. The courts and jails are overwhelmed, and recidivism is high. And opioid addiction for example, has reached into the middle class as well, to include professional and sports groups. The recent legalization of the sale of marijuana in city outlets has brought more focus on drug use generally, leaving people with the impression that taking drugs – like alcohol – is okay. Time will tell how society will cope with the ramifications of alcohol and now hard drug use as ‘normal’, and with the normalization of high powered illicit drug use. We can only hope that the guardians of society’s victims do not themselves become victims.

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Physicians and Touching the Human Body: Coming to Terms with Moral Codes and Temptations in the Workplace

The power of implicit (situational) and explicit (written) ‘codes’ about who can touch whom, and when, where and how, in society, extends particularly to healthcare institutions in which certain professionals are granted the right to touch patients in ways not afforded to other people. These are regulated norms, unlike lovers for example, who can make their own on a daily basis. Parents of newborns and young children are expected to have these ‘rights to touch’ as part of proper child-rearing. And physicians are expected to have similar rights as part of their professional role, circumscribed by explicit codes.

Not so for the rest of us. Permission must be given either orally or in writing by post-pubescent children and adults, to allow others to touch them. Even with prepubescent children, teachers for example, cannot touch students outside of school-board regulations that may permit “limited” forms of contact, e.g., hand on the back or shoulder. Male teachers especially cannot hug girl students, and female teachers cannot hug boy students, at least by code. Same-sex hugging is also proscribed, especially towards male-to-male in educational settings. There are clear rules about what constitutes ‘appropriate’ and ‘inappropriate’ touching and sexual harassment within most public institutions and industrial organizations. This extends generally to public open areas as well, but varies by culture.

Anthony Synnott (1993) has charted cultures which are “contact” cultures and “non-contact” cultures according to degrees of ‘tactility’, following from earlier research that showed many people suffer from physical deprivation during their adult lives. He found, along with Argyle, Mead and Montagu, that there are specific cultures which have very low levels of tactility and those which have very high levels of tactility. These he summarized as follows:

Contact                                                                              Non-contact

South Europeans                                                            North Europeans                                           Greeks                                                                                Scandinavians                                               Turks                                                                                   North Americans                                         Latin Americans                                                              Indians                                                           Some African cultures                                                   Pakistanis

New Guineans                                                                  Japanese                                                                                                                                                                Chinese                                                                                                                                                                  Upper-class British

Synnott admitted however, that within any of these cultural areas “there is a wide range of individual and sub-cultural variation.” He found that for example, “Californians and Southerners are often more tactile than New Englanders, and francophone Quebecers , than English Canadians. Similarly in Latin America, women in Costa Rica interact closer and touch each other much more often than Columbia and Panama.” This finding, among others, points to how cross-cultural communication can be difficult in a hospital setting. And we have to remember that variations exist according to variables such as age, sex, social class, and religion, regardless of culture of origin.

So how does all this relate to physicians and touching?

Physicians, particularly surgeons, touch people, either with their hands (palpate), a stethoscope (heartbeat), or surgical tools (scalpel, sutures). They understand codes because they, like all physicians in Canada, take the Hippocratic Oath (to practice professional behaviour), and have to submit to ethical standards found within their own professional associations, plus adhere to local hospital policies, etc. They are expected to take the moral high-ground. And they are taught at schools of medicine about liability insurance insofar as it affects their private practice, especially in this case, the “non-qualifiable claims” clauses that may relate to inappropriate touching of patients and possible resulting law suits.

So this seems clear enough. But what about other factors that come into play in the physician-patient relationship? For example, the age, sex, ethnicity, socioeconomic status, situational power/authority, physical appearance, type of illness, patient mobility/immobility, and religion. How do these variables influence how, when, where, and why, patients are touched? Would the fact that the physician was a Latin male, fifty-years-old, single, Catholic, and Chair of the Oncology Department, play a role if the patient was a twenty-eight-year-old female, attractive, single, Muslim, and former beauty pageant winner, with a diagnosed breast cyst? What if the patient was a 92-year-old white British war Veteran, with dementia and severe psoriasis in his groin area, and the physician was a 30-year-old black Lesbian from southern France, and resident dermatologist? Would that have an effect on their interactions re touching of his body?

In either case, who would touch who, where, when, how and why? The possible combinations of ‘causal’ variables appears endless, especially in diverse culures.

Or, would none of these sociological factors have an effect on how the physician treated the patient? How would being a member of a “low contact” or “high contact” touching culture mitigate patient-physician relations?

The urgency to conclude that simply being a professional ‘protects’ you from inappropriate touching, is offset unfortunately, by actual cases of malpractice involving inappropriate touching/sexual harassment (lower rates in Canada, much higher rates in the US). Going to Google Scholar will show the reader examples of Canadian infractions of touching code infractions. See also:

https://www.thestar.com. April 29, 2016. ‘Sexual touching’ case highlights a loophole for doctors guilty of abuse…

http://www.cbc.ca/news/canada/manitoba/doctors-discipline-patient-boundaries. ‘Disciplined doctors’ often given 2nd chance to practise…

Written and implicit codes do work the vast majority of the time. Tort law, costs, hospital ethics committees, and codes of conduct extract compliant,  and it yet should be firmly stated that no profession (medicine, teaching, police, military, accounting, real estate, engineering, and so forth) is post facto exempt from behaviour sanctions. Nor are private citizens, exempt from the laws of the land.

But the context of traditional medical care (and physiotherapy or chiropractic), in which patients have to take their clothes off either in part or totally, and dress in a flimsy gown in order to be examined more thoroughly, transforms the prior dressed, more egalitarian state, into a state of complete subservience, body vulneability, and expected conformity. The power balance shifts to ‘doing what the doctor asks’ (or nurse) and defers to his or her expertise. The patient by definiion, becomes a temporary social ‘deviant’, and is expected to play the ‘sick role’ (Parsons). This state of dependency makes the patient vulnerable, protected situationally by an often non-visual or buried-in-adminstration “Patient’ Rights” code. This doctor-patient situation can be made worse when medical ethics and organizational ethics come into conflict (Hall). Or especially when there are multiple physicians attending to one patient, not to mention the whole corps of ‘ancillary staff’ behind the scenes -which multiplies the possibilities of things going wrong (as well as going right). Illegitimate touching can be like background noise at a rock concert; no one notices.

As the main communication of reassurance and healing, touch can be central to a physician’s role. But it can be controlled beyond codes immediately known to the physician, as in the case where a husband unexpectedly accompanies his wife into the examining room, where religious values of modesty and/or patriarchy override the physician’s usual degrees of freedom.

Western society suffers from a lack of tactility. We don’t touch each other enough in a non-sexual way. Older people for example, who are isolated from the community or live alone, particularly are susceptible to the mental and physical health hazards from not being touched. Physicians readily have this opportunity of redress with the elderly. Nonetheless, this patient group is not where most problems occur, when they do occur. It most often occurs in situations where there is opportunity and motive for sexual assault involving younger patients. Following moral codes every day, and while being vigilant about liability, is the bane of physicians’ modus operandi. Being careful can haunt one, to the point of much raised anxiety, especially as often found in recent medical school graduates. More normalized touching in society that is free from sexual implications, may reduce among everyone, inappropriate touching, simply through body acceptance and familiarity.

“Touch is many things, and has many meanings; it is magical and cosmic, healing and therapeutic, a product of merchandising technique, a prime mode of communication, soothing or arousing, loving or murderous, creative, polluting, energizing, an expression of power, and also occasionally a problem in individual, cross-gender and cross-cultural communication. It is essential for human physical, emotional and intellectual development, yet also strangely taboo.” (Synnott: 180)

Finally “We need to understand that we have for too long neglected and overlooked the importance of tactile communication not alone in the development of the infant and child, but also in the development of the adult” (Montagu, 1979: 335)

Perhaps it’s time we all incorporated more touching into our lives, but within the margins of legality, respect, need, and care.

TL Hill, PhD                                                                                                                                                         Medical Sociologist

References:

Argyle, Michael. (1978). The Psychology of Interpersonal Behaviour. 3rd edn. Harmondsworth: Penguin Books

Hall, Robert T. (2000). An Introduction to Healthcare Organization Ethics. New York: Oxford

Mead, Margaret. (1956). Sex and Temperament in Three Pimitive Societies. New York: New American Library/Mentor Books

Montagu, Ashley. (1978). Touching: The Human Significance of the Skin. 2nd edn. New York: Harper Colophon Books

Parson, Talcott. ((1975). “The sick role and the role of the physician reconsidered.” Milbank Memorial Fund Quarterly, 53: 257-278

Synnott, Anthony. (1993). The Body Social: Symbolism, Self and Society. London: Routledge

 

Aging and Perspective

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When I think back about high school years, sporting black hair and only weighing 147 lbs, my perspective on life was to see it as wondrous, hopeful, and exciting. My project time frames were short (as far as next week), and my ideas unpredictable.

After the air force, marriage, and university, my perspective started to change considerably, to embrace mortality as a definite thing, and to accept living on an old farm and driving 47 kms twice a day to work in the city, as the way things were meant to be. The loss of our two children within about 11 years of each other, was not.

Then, in my 50s and 60s, after many jobs and more degrees, and especially after also losing friends to cancer, and my parents to a stroke and pneumonia, life seemed precious. Time began to speed up. Health issues further aggravated this encroaching “carpe deum” philosophy, and I suddenly found myself enjoying conversation like never before. Slowing down in every way was looking better. After all, I had taught university long enough, directed several colleges and departments, written over 40 articles and book chapters, and successfully (with blips) raised two healthy daughters, plus re-marrying 13 years ago.

I still live in the country though, and consult, write and cut grass. And have regular ‘happy hours’ whereby I can take a cold beer or a sherry onto the deck, look out over the river, and converse for hours with our long-time close friends who live with us. Statistically, I have 12.7 years left in this current corpus delecti, and my bucket list might be too long. But I am not caring about being dilatory, or not quick-on-the-board-game-draw; rather, I contemplate my perspective on life in hedonistic and altruistic terms. I like happiness from doing what I like doing, and I enjoy helping others who are struggling. I find I read happy books now, not tragedies or sad biographies. I hug my wife every chance I get, and hug strangers if I feel they need it.

So life perspectives change with time and experience, and the aphorism is true…life is what you make it. Mistakes and all, but keeping upbeat is crucial. At 71, I still want to climb a tree.

Living is dying and dying is living: So what’s the issue?

More body cells die after about age 30 than what are being replenished. So what sense does it make to distinguish dying from a disease and dying from normal aging?

We all die. Some take longer than others if disease is staved off. Whether it’s from an accident, a chronic or acute illness, homicide, war, or suicide, or age-related organ failure – death is inevitable.

Well, the issue of course, is dying prematurely, and the fear and/or grieving associated with it. But it’s also dying maturely, since anticipatory grieving occurs among survivors and the person as well, even if he or she is extremely old. We fear death, our own, and another’s whom we love or admire.

Society-wide fear of death and dying is endemic to all human cultures. The psychological make-up of humans makes loss an emotional experience, and this phenomenon is seen as an evolved survival mechanism. Avoidance of physical and psychological pain is primarily a human trait, although psychological reactions to loss have been attributed to higher order animals as well, as in dolphins, whales, elephants, apes and some birds.

Humans can actually suffer (crying, moaning, sleeplessness, physical distress, bad decisions, etc.) when someone dies. And can suffer or grieve for extended periods. Years, in some cases. Grieving that lasts a long time and interferes with activities of daily living, like work or social routines, may be classified as “complicated” or “pathological” grief. It may require professional intervention. In normal grieving the walls of pain get thinner and further apart with the passage of time, but may never completely go away. Nonetheless, within months from experiencing a loss the survivor usually returns to former daily activities.

The acceptance of death from aging, as part of normal life, may be better tolerated than a sudden, or unexpected loss. Or much more predictably, than the loss of a child. Or than the manner of the loss, as in a homicide or suicide.

The subjectivity of the loss varies depending on time, place, and circumstance. But humans die, however the means. Cellular death, it can be argued, is a form of dying of the whole body, and without restrictions, is seen as “normal”. The dying are still “alive’ until certain criteria are satisfied to declare them officially “dead” (although we also speak of someone suffering a ‘social’ death).

The issue is one of acceptance of death as a part of life, and education can go a long way in facilitating this acceptance.