Dr. Barry Dworkin » Addiction

“It must be my fault”

Dr. Barry Dworkin — Mon, 23 May 2005 03:33:42 +0000

Originally published in The Ottawa Citizen, May 22, 2005
Originally titled “Too Many Children Suffer in Silence”

Although many people are aware of the effects of alcohol abuse on family and friends, missing from this equation is a child’s reaction to a parent who drinks too much.

Young children have a difficult time understanding why their mother or father’s behaviour and actions can be so hurtful to them. Their questions and concerns often go unanswered because often alcohol abuse remains a family secret that no one wants to talk about.

The child’s fears and worries grow when no answers are forthcoming or the information provided to them is incomplete. The Centre for Addiction and Mental Health (CAMH), affiliated with the University of Toronto, cites research that shows children have many questions about their parents’ substance use or mental health but there is a lack of resources to help explain these problems to them.

A new storybook produced by CAMH entitled Wishes and Worries: A story to help children understand a parent who drinks too much alcohol, was released in April 2005 and written for five to ten year-old children.

Dr. Bruce Ballon, a psychiatrist in CAMH’s Youth and Addiction program and part of the writing team states that most children think that they cannot talk to anyone about their parent’s drinking problem. However, it is a subject that should be talked about and there is support available.

The storybook’s premise is to help children understand that they are not to blame for their parent’s drinking problem and behaviours. Children, for lack of information and understanding will usually blame themselves for the problem; they must be doing something wrong. They will come to the conclusion that somehow they must have upset their mother or father or that they are unlovable. If left to fester, it can affect their self-esteem and mood potentially leading to other problems later in life.

Indeed, Ballon points out that some may develop problems forging strong and healthy relationships or end up blaming themselves for other people’s actions because of the environment they grew up in. They also may be predisposed either genetically or due to their environment to use drugs or alcohol in response to stressful life events. Early intervention or prevention is the key to address these issues.

Wishes and Worries tells the story of Maggie, an eight year-old girl, who has experienced one disappointment and embarrassment after another because of her father’s drinking. With her ninth birthday coming up, she is worried that he will ruin her party as he did on her eight birthday. She feels quite sad and unsure of what is happening and blames herself for his behaviour. Throughout the story she learns that there are friends, family members and professionals who are available to help her understand her father’s alcohol abuse.

The book is beautifully illustrated and well written. Prior to the story’s introduction there is a page that contains information for parents about the book and they can use it to help their children understand alcoholism. The following page is designed for children and provides information about a parent who drinks and lists the different people they can talk to about their fears and concerns.

It will generate a good discussion between you and your child.

The storybook can be purchased from CAMH by calling 1-800-661-1111 or on-line at www.camh.net.

Club Drug Use Carries Uncertain Risks

Dr. Barry Dworkin — Tue, 26 Apr 2005 03:29:58 +0000

Originally published in The Ottawa Citizen April 25, 2005
Original Title: Three More Members of the Club

Part One
Final of two parts

When discussing the potential side effects of drugs, risks must be viewed within a realistic context. Indeed, my last column on Ecstasy, or MDMA, and today’s on GHB (gamma-hydroxybutyrate), Rohypnol (flunitrazepam) and ketamine, contain information that is factually correct.

Each person reacts differently to the effects of a drug.

GHB, developed in 1960 by the French as an anesthetic, is a salty powder that is dissolved in water. It is manufactured from common industrial chemicals that can be purchased with home-production instruction manuals from websites.

It is structurally similar to a naturally occurring central nervous system transmitter, gamma-aminobutyric acid (GABA). GABA is believed to regulate sleep cycles, body temperature, memory and brain glucose levels. Its unpleasant salty or soapy taste can be masked by mixing it in flavoured or alcoholic drinks.

GHB’s effects are dose-dependent. The initial euphoria occurs about 15 to 30 minutes after ingestion, reaching a peak in 20 to 60 minutes. This effect can be tempered if taken with food. The use of alcohol or other central nervous system depressants can increase GHB’s potential toxic effects. The drug’s concentration within the powder is not known, increasing the risk of overdose.

The signs and symptoms of GHB intake that can precede overdose are dizziness, increased salivation, muscle relaxation and amnesia. There is evidence to suggest that as the level of consciousness wanes, the risk of a slower heart rate (bradycardia) and low body temperature (hypothermia) increases. Overdose might lead to abnormal and ineffective breathing patterns, seizures, coma and death. Recognition of the early signs and symptoms can help prevent this outcome.

Long-term regular users of GHB might develop drug dependence. The withdrawal syndrome can include insomnia, tremors and anxiety.

The drug Rohypnol, also known as the date-rape drug, is the same class of medication as Valium: It is a potent benzodiazepine. This prescription drug is available in many European and Latin American countries for use as a preoperative anesthetic, sedation, and as a treatment for insomnia. Being a prescription drug, there is quality control in its manufacturing process.

Rohypnol can induce sleep (hypnotic), reduce stress, inhibition and anxiety through sedation, and is a muscle relaxant at doses of one to two milligrams. The onset of action is about 30 minutes after ingestion, with a peak effect occurring after two hours. The drug’s effect can last up to 12 hours.

Exceeding the recommended dose can lead to loss of memory of events occurring from the time of ingestion onward (anterograde amnesia), lack of muscle control and loss of consciousness. Users who consume alcohol can increase the drug’s effect.

Depending on the dose and other concurrent drug use, some users can develop low blood pressure, confusion, dizziness, aggressive behaviour, urinary retention (inability to urinate) and visual disturbances.

Benzodiazepines are not usually recommended for long-term use because of the high risk of drug dependence. Some prescription benzodiazepines can cause dependence with two to three weeks of daily use. Withdrawal must be medically supervised in order to prevent seizures.

Ketamine is a derivative of phencyclidine (PCP). It prevents brain cells (neurons) to reclaim various neurotransmitter compounds that are released by one neuron to communicate with another. The neurotransmitter levels can build up and overstimulate certain brain areas. This effect can cause hallucinations and strange thoughts and ideations.

Ketamine is difficult to produce in a home lab because it requires a specialized manufacturing process. Most of the supply is taken from veterinary and human anesthesia products. Pharmaceutical grade ketamine comes as a liquid that can be swallowed or injected. Club users will allow the liquid to evaporate in order to collect the powder. The powder can be mixed with tobacco or cannabis and smoked or snorted.

Ketamine has a rapid onset of action that lasts 30 to 45 minutes. It can cause a dreamlike state or a feeling of floating outside the body. Increasing doses can lead to confusion, anterograde amnesia and delirium. Depending on the dose, other drug and alcohol ingestion and the person’s ability to metabolize the drug(s), some can develop hypertension, rapid heart rate (tachycardia), palpitations, a reduction in breathing effort (respiratory depression) with periods of apnea (no breathing).

Chronic users can become addicted. Withdrawal can be severe and require medical supervision to assist in the detoxification process.

The purpose of this series was to provide information about what is known about these drugs and not to be interpreted as scaremongering.

Information should be provided within a frame of reference or context that provides the reader with a means to gauge true risk. To wit, some users will not experience the severe side effects of club drugs; others will.

More research is required to provide people with an accurate assessment of their chances of experiencing these harmful effects. Until then, the user is travelling through uncertain risk territory.

The Club of Tortured Souls

Dr. Barry Dworkin — Tue, 05 Apr 2005 03:27:11 +0000

Originally published in The Ottawa Citizen April4, 2005

First of two parts

Recently, one of my patients with bipolar disorder took Ecstasy at a rave. Within 60 minutes she had collapsed on the dance floor from dehydration.

After a thorough assessment in the emergency room, she was given intravenous fluid replacement and sent home. The following day she came to my office for a follow-up visit, experiencing a precipitous decline in her mood.

This two-part series will look at four commonly used club drugs: Ecstasy (3,4-methylenedioxymethamphetamine or MDMA), GHB (gamma-hydroxybutyrate), Rohypnol or the date-rape drug (flunitrazepam), and ketamine. How do these drugs work and what are the health risks?

The club drugs stimulate the release of the neurotransmitters serotonin, norepinephrine and dopamine from brain cells. These neurotransmitters are intimately involved with mood stability. People use club drugs to enhance social interaction: They feel less inhibited and experience increased empathy, physical closeness and euphoria.

MDMA is the drug of choice at a majority of raves. It is an amphetamine derivative originally developed in 1914 for use as an appetite suppressant, but it never got past animal testing. Its chemical structure is similar to the hallucinogen mescaline. MDMA is addictive but less so than amphetamine, and it does not cause psychosis as often as LSD or other hallucinogens.

Many of the illicitly manufactured MDMA tablets are not pharmaceutical grade. They can contain “binders” or extra ingredients such as caffeine, dextromethorphan (cough suppressant), pseudoephedrine (decongestant), or hallucinogens like LSD or other potent amphetamine derivatives. The latter two ingredients in combination with MDMA can have strong unpleasant hallucinogenic effects.

MDMA’s effects occur 30 to 60 minutes after ingestion, faster if it is crushed or if its powder form is snorted. The effects can last up to eight hours. Serotonin, dopamine and norepinephrine flood the synapses or spaces between the nerve cells. This effect is enhanced by MDMA’s ability to block a brain enzyme that breaks down these neurotransmitters.

The euphoria occurs after a brief feeling of agitation, time disorientation, lack of appetite and reduced thirst. Some people may experience a mildly locked jaw (trismus) or will grind their teeth (bruxism). Both of these side effects can be tempered by sucking on a lollipop.

The overstimulation of the brain and central nervous system can lead to a serious life-threatening condition. The heart rate and blood pressure can increase above acceptable limits. Some users will experience tremors, seizures, clinically significant irregular heart beat (arrythmias), parkinsonism, esophoria (the eyes turn inward — cross-eyed) and an inability to urinate (urinary retention).

The most serious side effect of MDMA ingestion is an elevated core body temperature (hyperthermia) due to serotonin syndrome. This syndrome can lead to muscle rigidity and seizures, muscle breakdown (rhabdomyolysis), acute kidney and liver failure, adult respiratory distress syndrome, and blood clotting abnormalities.

MDMA also stimulates the pituitary gland in the brain to release antidiuretic hormone (ADH). This hormone will reduce the kidneys’ ability to produce urine in response to an increased fluid load; they cannot excrete water into the bladder.

This creates a ‘perfect storm’ of pathology. The body overheats from dancing and the effects of the drug. The kidneys shut down. The user will dramatically increase his or her intake of water and other fluids in response to increased body temperature. Without the kidney’s ability to excrete water, the fluid overload reduces the blood sodium concentration (hyponatremia) through dilution. Low sodium concentration levels coupled with high body temperatures can cause confusion, delirium, paranoia, headache, anorexia, depression, insomnia, irritability, and a rapid, involuntary, oscillatory motion of the eyeball (nystagmus), all of which may continue for several weeks.

Several days after using ecstasy, the effects of serotonin depletion can cause depression, and for some it is severe. People who repeatedly use MDMA increase their risk of cognitive deficits and potentially permanent memory impairment.

MDMA does change the brain’s normal function. Indeed, studies indicate that long-term use in typical recreational doses can lead to a paranoid psychosis that cannot in practice be distinguished from schizophrenia. Prolonged drug abstention will lead to a reversal of the psychosis.

There are some animal and human studies that indicate that MDMA use (possibly in conjunction with cannabis) can lead to cognitive decline in otherwise healthy young people.

My patient with bipolar disorder experienced a precipitous decline in mood because the MDMA depleted the serotonin stores in her brain. People with mental illness are more vulnerable to the deleterious effects of MDMA and other club drugs. It is akin to a patient with asthma or chronic lung disease who smokes. They will tend to have more severe disease and attacks than someone who does not smoke.

These drugs are adulterated with other chemical additives and, although most club drugs look like prescription medicines, they are illegally made and can cause harm even in small doses.

I will return to the club in my next column to review GHB, Rohypnol and ketamine.

The betterment of one’s life

Dr. Barry Dworkin — Tue, 27 Jan 2004 22:49:53 +0000

Originally published in The Ottawa Citizen January 27, 2004

Original Title: The betterment of one’s life

A common student question asked at Canterbury High School focuses upon the melange of moral, ethical and consequential aspects of smoking cannabis.A previous column focused on the physiological and psychological effects of drug use, especially marijuana/cannabis. After my column about the latest research on the effects of cannabis, many readers wrote to express their opinion about the issue. One e-mail caught my attention.

Deborah is a 37 year-old single woman with three boys aged 10, 12 and 14. She first tried marijuana at age 11 and started regular use by the time she was 15. She quit during the five years encompassing her pregnancies but restarted after her youngest son’s first birthday. She smokes an average of four to 10 joints daily. She does not drink or smoke cigarettes.

She comes “from a good upper middle class family.” Her father was in the armed forces and her mother worked for the government. Her sister works at the Department of National Defence and is active in her church. Deborah works for several physicians and was a registered practical nurse for 15 years.

Deborah says, “I have always been very ambitious, adventurous and seemed to have excelled in everything I have attempted; drama, track and field, horseback riding, skiing, skydiving, rock climbing, guitar, keyboards, drums and singing.”

Her concern was that her marijuana use was jeopardizing her health. Her feelings of shame prohibited her from discussing this issue with her family doctor. She feared “what she might think of me, as a person, a mother, and a professional.”

She often feels pressure or pain in her chest and cannot breathe as easily as before. She worries that she may have cancer of the mouth, throat, lungs or stomach from her smoking.

She asked if I might help her quit using cannabis. (There was no precondition that her story would be published.)

She had three goals: to show teens the long-term physical and psychological effects of cannabis; to discourage its use; and to “get some much needed help so that three beautiful little boys will have a mom around for a long time.”

In addition to her desire to quit her cannabis use, she wanted a full physical exam and tests to determine whether she suffered any deleterious health effects.

During her first visit last October, she stated she was experiencing mild, manageable mood swings. She could concentrate and functioned well at work. She had normal sleep patterns and appetite.

She stated she was a high achiever with many goals and dreams. She expressed frustration that she could not sing as she once could or motivate herself to achieve her goals.

She smoked outside of the house and never in front of the children. However, they knew what was going on. Her guilt about the message she was sending to her children was unbearable.

Her physical exam and blood tests were normal. A lung function test indicated the smaller airways were becoming blocked. The chest X-ray was normal.

The question “why does she continue to smoke?” does not necessarily have a straightforward answer. We know she started at age 15, the middle or tribal stage of adolescent development. In this stage, there is a consolidation of body image and sexual identity. The school environment is comfortable. Peer groups become their new family and safe haven and are a form of tribalism with all its rituals, markings and lingo. Peer pressure becomes the dominant behavioural influence. In the quest for independence they test their limits and compare themselves to their friends. Paradoxically, they conform to their peer group in order to feel more independent.

Drug abuse during adolescence will arrest or hinder progression through the developmental stages that lead to independence and self-awareness. Indeed, Deborah readily admits she has difficulty defining who she is. At 37, she remains stuck in her adolescent middle stage. Although she appears to be coping with many of her responsibilities on an adult level, her sense of self remains undefined.

I usually give my adolescent patients some “homework” after the preliminary evaluation to better understand their concept of friendship, relationships and their self-image. These questions are part of the Adolescent Toolkit (http://members.rogers.com/barrydworkin/help_teens_tune_in.html) and are germane to Deborah’s situation:

- What do you like and dislike about yourself?

- What are your good and bad qualities?

- What are your definitions of a friendship and relationship?

The goal for Deborah is to understand why she smokes, gain control over her behaviour and achieve true independence.

Next week’s column will review Deborah’s progress.

Students stressed, desperate for help

Dr. Barry Dworkin — Fri, 28 Mar 2003 04:34:34 +0000

Originally published in The Ottawa Citizen March 27, 2003
Original Title: What society has wrought

One of the more difficult aspects of answering teen questions is the degree of angst and pain that spills from them. Although the majority of our teenage children progress through adolescence to become well-adjusted, productive adults, a substantial minority is desperate for help during life’s stressful events.

A recent annual Academy of Child and Adolescent Psychiatry meeting supports this view. A U.S.-wide survey of 3,242 teens and young adults indicates one-third experience a bout of depression. Two-thirds of this group fail to seek professional help.

The survey indicates that 36.4 per cent of teens between 15 and 19 experience a bout of depressed mood lasting two weeks or longer, at least once in their lives. About seven per cent have symptoms that suggest a major depressive disorder. Depression is a major health risk to teens.

The incidence of teen suicide climbs. “Less than 20 per cent of teens will tell a doctor about their (depressive) symptoms,” reports Dr. Stephanie Riolo of the University of Michigan.

“Of those who tell, girls seek help more often than boys do.”

This is similar to my experience at Canterbury High School clinics. Many teens are reticent and intimidated from seeking medical attention; they fear their family doctor will breach confidentiality and inform their parents. Some seek solace from friends or acquaintances, only to find the support underwhelming or ineffective.

The teen years are a time for personal growth and development. Adolescents develop different areas of interests, life and educational goals, and a sense of self through the three stages of adolescence. Although dating and social interactions are an important element of adolescent development, for some it becomes an all-consuming process. They can become stuck in a particular stage of development.

Drug use poses a similar threat. One observation made by the guidance counsellors and our medical centre at Canterbury is that many teens become trapped within destructive relationships. Friends and family are forgotten.

Some lose themselves in the relationship; their moods and actions are influenced by the actions of their partner. The dynamics of their relationship change if they become sexually active. There is the anxiety of infidelity, sexually transmitted diseases, pregnancy and the consequences of any of these concerns.

There are many reasons why this occurs: parental strife, divorce, laissez-faire approaches to discipline, lack of parental involvement and support, lax enforcement of the rules of the house, poor sense of self and depressive illness among others. Sometimes, there’s no apparent explanation.

This is not an indictment of parents but based on direct observation and interviews with the students.

Here, the students have their say:

Grade 9

“What do you do when you get so upset that you think people would be better off without you?”

“If my boyfriend has slept with another girl before, is it best to have him tested? And why?”

“If I had a friend who I thought was being abused by her father, should I come to you or what should I do?”

“A friend of mine is really depressed. And, he wants to die although he said he could never go through with it. He says that he can’t live like this any more, and that he won’t tell anyone until OAC, when he won’t see any of us again. I hate to see him like this. How can I persuade him to get help?”

“Depression and suicide run in my family. I’ve heard that it can be caused by a chemical imbalance and is curable. Is that true?”

“A close friend of mine has had a hard life. She’s been anorexic and bulimic for eight years now. She’s 5-foot-2 and 75 pounds. I’ve tried to get her help but they say she’s not ready for a program yet. I’m really worried about her.”

“I have a lot of problems and things going on in my life and I don’t feel like I have anyone to talk to. I’m worried that my problems are going to start taking control of my life and I don’t know where to turn. How do I get help and who do I go to?”

Grade 10

“I used to trust everyone but within the past two years three guys (who I was serious about) cheated on me and friends have betrayed me. Now I can’t trust anyone at all. Even friends I’ve known since I was a baby. How can I get over this trust issue and trust again?”

“Is there such a thing as a social anxiety disorder — when you are so wrapped up in what other people think of you, you don’t enjoy your friends or whatever.”

“I have a friend who is a frequent self-mutilator. I’m afraid her cuts will get infected. I’m not worried about suicide because she only cuts her legs but I’d like to know what is the risk factor of infection. She uses razors mostly but scissors sometimes. What can I do?”

“I started having sex a year ago when I was 15, and my vagina was very tight. My boyfriend could not reach full penetration, and once I blacked out. Why is this and what can help?”

Grade 11

“For years, my dad’s girlfriend hated me. She used to insult me and tell me my real mother hated me. She tried to run me over with her car. I told myself I didn’t care but I guess I really did. This I guess went on for four or five years and I’ve never talked about it. My new stepmother says that because I was older (11+), it didn’t affect me, but it does.”

“I’m very shy and am always trying to make people happy. I want to talk to someone but I’m afraid. I find that I get excessively angry and violent at times. When I feel this way, I feel like hurting or destroying someone or something. Is there something wrong with me?”

One is struck by the concreteness of some sexuality questions. There is little emphasis on the appropriateness of the activities described. Should our children have to worry about these issues? How can we prevent this behaviour?

Many teens are adrift, lacking direction and focus. Once they find someone they trust, they tend to stick with them. Trust provides the ability to influence a teen’s life. The goal is to minimize and if possible eliminate behaviours that are inherently self-destructive.

Survey shows youth drug use up in past decade

Dr. Barry Dworkin — Thu, 27 Mar 2003 04:36:40 +0000

Originally published in The Ottawa Citizen March 26, 2003
Original Title: What teens want to know: Drugs

In this continuing series based on teens’ questions asked at Canterbury High School, today’s column looks at the drug issue, which is all too often intertwined with the issue of sex among teenagers.

The 2001 Ontario Student Drug Use Survey, a study conducted by the Centre for Addiction and Mental Health (CAMH) every two years since 1977, looked at legal and illicit drug use by more than 4,200 students from Grade 7 to OAC.

“The 1980s were a period of decline of drug use, the ’90s had a resurgence and in 2001 the good news is that illicit drug use among youth isn’t growing — the bad news is it’s still higher than it was in the early ’90s,” according to Dr. Edward Adlaf, the senior scientist at CAMH and associate professor at the University of Toronto who conducted the study.

For the first time since 1991, the survey did not show any year-over-year increase in drug use. However, most measures continue to be significantly greater than the 1993 rates. Alcohol remains the top dog in this department. In 2001, 63 per cent of students drank, versus 57 per cent in 1993.

Further, binge drinking — defined as downing five or more drinks at one time — was reported by 25 per cent of youth in 2001, compared with 18 per cent in 1993. Inebriation rates increased from 17 per cent in 1993 to 27 per cent in 2001.

Between 1999 and 2001, cigarette use declined from 29 to 24 per cent, solvents from seven to six per cent and LSD from seven to five per cent.

The student drug-use survey highlights include:

Students today are not using alcohol, tobacco or cannabis at an early age.
The percentage of new users has not increased over time.
Although rates of drinking and driving among licensed students remained stable at 15 per cent, about 32 per cent of all students report being a passenger in a vehicle driven by someone who had been drinking, and 19 per cent of drivers reported driving after using cannabis.
Perceptions about the risks of using cannabis, cocaine and LSD seem to be weakening over time.
Toronto students use alcohol at a lower-than-average rate, while western Ontario students report above-average use of cannabis, heroin, methamphetamine, cocaine, crack, hallucinogens and ecstasy. Northern Ontario students have a higher rate of alcohol and binge drinking.
Females reported higher rates of non-medical stimulant use, while males reported higher rates of heavy drinking, cannabis, glue, methamphetamine, LSD and hallucinogens.
Drug use was lowest among 7th-graders and highest among 11th- or 12th-graders — with the exception of inhalants, that showed greater use among younger students.
These statistics correlate with the questions students pose in the classroom. Teens want to know what drugs will do to them. Their questions are to the point and reflect an interesting dichotomy between immediate versus long-term harm.

They seek a frame of reference to compare the risk by invoking another drug or activity for risk assessment comparisons.

These Grade 9 questions reflect a desire to understand the issues:

“What are the side-effects of the drug mescaline? What is it?”

“My best friend used to be anorexic and bulimic and now uses a whole bunch of drugs. Her parents know, but they refuse to take action. All of her friends are the same way. What do I do?”

“How fast will smoking kill you, ’cause I don’t want to die?”

“Is it true you lose brain cells if you do drugs? If so, what exactly do drugs do to you?”

“How do I tell my parents about my drinking problem?”

“My friend throws up every time she gets drunk. This is normal, but the same things happens when she smokes marijuana. Is she allergic? If so, how can she find out the consequences of trying acid or other drugs?”

“Does alcohol stunt the growth of your boobs or anything else? Also, if you drink a lot as a teen but stop after a few years, will you have liver problems?”

“I’ve been doing drugs for a while and probably done just about every drug you can think of. I also get depressed a lot and I find drugs help me to escape for a while. I don’t want to quit drugs, but I want the depression to go away. What should I do?”

“I heard that smoking pot does not harm you at all because it is a natural drug, but all that is harmful is the smoke. Is this true?”

“Is there such a thing as a weekend alcoholic?”

“If one of my parents is an alcoholic, what are my chances of being an alcoholic?”

“Some of my friends that smoke weed, their grade-point average is going down. I smoke about two to three times a week, but it hasn’t really affected my school work. Why is that?”

“If you do drugs and have a high tolerance level, does it have the same effect on the body and mind?”

“What effect does cocaine have on a person if they done it just once? Or more?”

“What would be the difference smoking weed or smoking weed laced with cocaine?”

“How long do drugs stay in your bloodstream? If the doctor takes a urine sample, can they detect drugs?”

“When my friends are talking about drinking or getting drunk, it makes me feel very uneasy. What should I say to them? I don’t want them to get drunk. I feel very scared about alcohol and what it can do to you.”

Our teens want our help. Their questions call out for guidance through the maze of half-truths and peer pressure. Most parents have the unique opportunity to guide their children through the morass.

How do you get herpes?

Dr. Barry Dworkin — Wed, 26 Mar 2003 04:27:39 +0000

Originally published in The Ottawa Citizen March 25, 2003
Original Title: What teens want to know: Real Questions, Real Answers

How have society’s changing attitudes about sexual activity and responsibility affected our teenage children?

The Medical Institute for Sexual Health, a U.S. non-profit group promoting sexual abstinence outside marriage, lists the devastating toll laissez-faire attitudes have had on our teens.

Its data are supported by similar reports by the U.S. Centers for Disease Control.

The medical institute raises concerns that providing sexual health information without moral context and consequence is harming our children.

The institute’s review of the data indicates that our children’s emotional and physical health is at risk.

Half of all 13- to 17-year-olds will become sexually active. Twenty-five per cent of all sexually active teens have a sexually transmitted disease.

Over 20 years, the prevalence (number of existing cases in a given population) of genital herpes in children 12 to 19 years old increased by 500 per cent. Chlamydia, a leading cause of infertility in women, occurs in one in 10 teenage girls, half of all cases in 15- to 19-year-olds. Human papilloma virus, a leading cause of cervical cancer, is reaching epidemic levels in the teen and young adult age group. Teenage girls with the virus are more susceptible to cervical cell changes that lead to cancer, compared with adult women.

Oral sex is a means for some girls to maintain they are virgins. Many do not see oral sex as being sexually active. Many teens do not even have a definition of what “sexually active” means.

As many as one in five of our teenagers are clinically depressed. Suicides have increased threefold in 30 years.

After nine years of giving health clinics at Canterbury High School, thousands of patient visits and hundreds of handwritten anonymous questions answered during classroom visits, these reports and statistics lead me to accept them for what they are: the truth.

Before writing me off as alarmist, please read what your children have had to say:

Grade 9

“What happens if when you’re having oral sex, you swallow sperm?

“If a girl swallows my sperm, will she be pregnant?”

“How is abortion performed?”

“What is the average of females being raped and beaten in the ages 14 to 16?”

“How does Viagra work?”

“As a male, if I impregnate a girl, what are my obligations?”

“Can you get pregnant without having sex?”

“My friend used to have a boyfriend who hit her and treated her like crap. He even used to use her for sex. Now he wants to get back together with her and she hasn’t made up her mind. As a best friend, what should I say to her to make the right decision without hurting our friendship?”

“Do males have to ejaculate or is it something they choose to do?”

“Can you arrange an abortion without our parents knowing?”

“Can a girl get pregnant if a guy ejaculates in a pool and she is near him?”

Grade 10

“Are there any risks for girls under 14 years other than pregnancy and STDs?”

“If you have intercourse with someone who has an STD, are you guaranteed to get the STD?”

“What is herpes? How can you get it? And how do you get rid of it?”

“My friend might be pregnant but she doesn’t want to have it. She doesn’t want to go to the doctor. She wants her friend to punch her in the stomach to kill the baby. I don’t think it’s right. What can I do to convince her to not do this?”

“Does the size of a man’s penis affect his personality?”

Grade 11

“Would it be safer to have sex now while we are younger, considering that the number of people who have AIDS is rising very quickly?”

“Is it illegal for a 15-year-old girl to be having sex with a 20-year-old guy? What if she’s 16?”

“Can you have an abortion when you are 16 without letting your parents know?”

“I just can’t handle it with the workload any more. I’ve had it trying to balance out school, homework, work, sports, friends and a boyfriend and especially parents. I’ve gotten to the point of nervous breakdown. I don’t sleep, hardly eat. I feel helpless. What can I do? P.S. What is hepatitis B and how do you catch it?”

These questions cut across all socio-economic and cultural strata. We must face this growing trend. We cannot ignore what is happening to our children. Many parents come into my office gravely concerned about their teen’s behaviour.

Teenagers, despite their protestations and efforts to act as adults, need guidance and support to become mature, caring adults.

The guidance centres on responsibility, respect, sexual behaviour and following the rules of the house.

Many parents try to be their children’s friend. The idea is the child will be more likely to accept you into their life. Parents hope they will have more influence on their child’s life decisions and actions.

This strategy, well-meaning and caring as it is, will not stand the test of time.

Friends do not tell friends when to go to bed. At some point, circumstances will dictate that parents will have to switch hats from friend to parent. Viva la revolucion!

Despite their challenges to your authority, teens do need their parents to be a foundation for morals, limits, rules, understanding and love, regardless of what the teens might say or do. Too many feel adrift in a sea of confusion. They need to know they can return safely to port.

As the questions above show, what possible benefit is it to a 15-year-old to have to worry about whether their boyfriend or girlfriend is cheating on them?

Why should they have to deal with the complications inherent in a sexual relationship on top of their educational, social and family responsibilities?

Why should they have to come into the office freaking out over whether they are pregnant or have an STD? Why are they worried about the effects of swallowing sperm? What can parents do? Quite a bit, but it is not an easy road.

Tomorrow night, Dr. Joanne Tannenbaum and I will present at the Citizen conference centre a forum for parents and teens called “What your teens want to know: Real answers to real questions.”

——————————————————————————–

Tomorrow’s column will look at teens and drugs.

Dr. Barry Dworkin is a family physician and an assistant professor of family medicine at the University of Ottawa.drbdworkin@hotmail.com

Read previous columns at members.rogers.com/barrydworkin/

Web Sites:

Medical Institute for Sexual Health: www.medinstitute.org

Centers for Disease Control: www.cdc.gov/nchstp/od/news/RevBrochure1pdf.htm

National Mental Health Association: www.nmha.org/infoctr/factsheets/24.cfm

Teen Sex: What You Need to Know

Saturday: The demise of dating: Why school kids have ‘buddysex.’

Sunday: In their own words: Students talk about hooking up.

Monday: In search of guidance: Health educators try to guide students through the morass and attempt to curb date rape by teaching the dangers of mixing alcohol and sex.

Today: Sex ed: What are they teaching our kids in elementary and high school? And Dr. Barry Dworkin on what teens really want to know about sex.

Tomorrow: High-school confidential: the Canterbury health clinic. And Dr. Barry Dworkin on kids and drugs.

Thursday: A look at what parents and teens have to say in Wednesday night’s public forum. And Dr. Barry Dworkin on the angst teens are dealing with on the subject of sex.

Friday: The consequences of the hooking-up culture: Where will society and divorce rates be in 20 years if we continue in this direction. And a reality check — teens are not the libertines they are portrayed as.

Public Forum on the Culture of Teen Sex

Parents, teens and others interested in the culture of ‘hooking up’ are invited to a Citizen-sponsored public forum held by Drs. Barry Dworkin and Joanne Tannenbaum, tomorrow at 6 p.m., at 1101 Baxter Rd. Register by e-mail at dworkinforum@thecitizen.canwest.com or by phone at 596-3664. Please include your name, phone number, and the number of people who plan to attend.

Cutting loose from tobacco

Dr. Barry Dworkin — Tue, 19 Nov 2002 13:06:02 +0000

Originally published in The Ottawa Citizen November 19, 2002
Original Title: Quitters are Winners

Most people know the risks of cigarette smoking. They often employ many strategies to quit, often with lukewarm success. An understanding of the addictive nature and the associated habits and triggers of smoking is essential before attempting a smoking cessation program.

Nicotine is one of the most addictive substances known: worse than heroin. It is strongly psychoactive, incorporating itself in the chemical processes of brain function. The term “addiction” is commonly misused. An addiction is condition wherein a person needs a particular substance or activity in order to continue to function. He/she will go to any length to procure the substance should it become scarce. The effect it has on the brain dictates their behaviour. In short, these people lose the ability to function independently compared to a non-addicted person.

To wit, how many smokers do you know who would not hesitate to head out into a stormy winter night to buy a pack of cigarettes should their supply be depleted? One only needs to look at the short-term nicotine withdrawal effects to understand how powerful a hold this drug has on behaviour and brain chemistry. True, some people can go without cigarettes for extended periods of time but the vast majority cannot.

There are two sides to nicotine addiction; the chemical addiction and learned behaviours. Indeed, think of the myriad of associations with cigarettes; coffee, alcohol, social gatherings, sex, peer group status, anxiety, and pleasure among the many others. Over the years these factors incorporate themselves into the fabric of a person’s day-to-day life. They become commonplace and achieve a status of normalcy as the person adapts to and accommodates the “smoking lifestyle”.

These triggering events or activities become so strong that people forget how the cigarette ended up in their hands. The conditioning of their behaviour is so insidious that their actions seem to be automatic without any forethought.

Some patients, fed up with smoking, will come to the office seeking the nicotine patch or Zyban to implement a quick-fix solution. Indeed the desire and motivation to quit smoking requires support and encouragement. However, an ad hoc approach to smoking cessation can lead to frustration and a greater chance of relapse.

Some people can quit cold-turkey, most cannot. How do you reverse years of conditioning and dependency?

The first and most important step is the motivation to quit. The smoker must want to quit, not for others, but for themselves.

The second step is to keep a written smoking log. The log should be in a table format with four columns; time, location, activity and mood. Each time a person lights up they enter this data. The log should include three consecutive work days and one day off. I ask patients to bring this record back a week later for review. Many will say they know when and where they smoke but the written record is often more accurate. It reveals smoking patterns and common triggers. Completing this log indicates a true motivation to quit.

Step three asks the smoker to create a list of personalized enjoyable activities (PEAs) to substitute for their cigarette smoking time. The smoking log provides the template. What can the smoker do at this particular time of day in this location that will be close to or just as enjoyable as smoking a cigarette?

For example, an ashtray (clean and pristine) is set on the desk filled with a low fat salad dressing or dipping sauce. Next to it are baby carrot sticks, celery, or other low fat food. The act of dipping the celery stick in the ashtray, taking a bite and placing it back in the ashtray mimics the act of smoking.

Preparing for a stop-date is step four. The PEAs have to be as available to the smoker as their cigarettes. They should be put in the locations (identified in the log) ahead of time. This preparation gives the smoker a sense of control. They are aware that they will have an alternative when the craving hits them.

The final preparatory step is addressing the chemical addiction. Two products are available to help reduce or eliminate the nicotine craving. By virtually eliminating the burdensome effects of nicotine withdrawal, the smoker has a window of opportunity to incorporate new habits in response to their smoking triggers.

Your doctor can help set up a program for you. Based on your state of health, he/she will review whether the nicotine patch or Zyban is safe for you to use. Both can be a useful adjunct to smoking cessation. Using both concomitantly does not significantly increase the success rate. Indeed, using them as step one instead of step five will invariably lead to relapse.

This five-step approach is an open-source guideline. Tailor it to your own needs. When used within a comprehensive smoking cessation plan, about 50 to 60 percent of quitters remain so after a year. Most smokers with the motivation to quit will eventually succeed. With each effort they learn a little bit more about themselves and fine tune the strategy for next time. Take the time to learn to quit. You already know the advantages of doing so.
© Dr. Barry Dworkin 2002

Which is worse: cigarette or joint?

Dr. Barry Dworkin — Wed, 22 May 2002 04:38:17 +0000

Originally published in The Ottawa Citizen May 21, 2002
Original Title: Searching for the Pot of Gold

You walk a fine line at times when responding to teens’ questions. One frequently asked centers around comparisons between marijuana, cigarettes and alcohol. For example, a common question is, “What is worse, smoking a joint or smoking a cigarette?”

At the outset, I do not condone the use of any drug, illicit or otherwise that compromises public safety, disrupts personal growth and development or interferes with a person’s day-to-day functioning (side effects of necessary medications notwithstanding).

These questions can be dangerous waters. On one side there is the parent in you that reaches for the staid paternalistic response, “Are you freaking crazy! What the hell are you thinking about?” This mild temperate response usually does not win over many converts.

The other side is more complex. The message must be clear, imply personal responsibility for actions and decisions, honest, respectful and challenging.

Teens know when you are feeding them a line. They want factual truthful answers to their questions without moralizing about their actions unless they themselves ask. They know many adults have smoked marijuana and continue to do so. That message is clear to them. A fresh approach is needed to convey the concerns of disruptive drug use.

They know that alcohol and cigarettes cause more death and suffering than all illicit drug use combined. So what is the message? Is one joint more or less harmful than one cigarette?

The smoke from a joint is held within the lungs for a longer period of time than cigarettes. More of the tar and other noxious and cancer-causing (carcinogenic) compounds settle within the lung. The difference in this case is quantity. Most cigarette smokers smoke more than one or two cigarettes a day whereas the pot smoker may smoke a joint a day or every other week. Over the long term, cigarettes win this skirmish for physical harm hands down.

However you do not get high from one cigarette. A joint has more potential for social and personal harm if smoked while driving, operating machinery and engaging in serious interpersonal conflict resolution. Alcohol inebriation produces similar harm.

As with any drug context for its use is important. Are the pot smoker’s school grades suffering? Are they losing the drive and motivation to pursue their dreams and life goals? Is it thwarting their normal adolescent development? Are interpersonal relationships suffering?

Is there a difference between being drunk or stoned? Aggression and uninhibited behaviour is more likely with the former state of inebriation. In both cases, if the person is safe at home is one drug more unacceptable than the other? If as a society we accept the message for responsible alcohol use, what would one say regarding marijuana if used under the same context?

What about other health risks? For the sake of argument let us assume that the dangers of alcohol and cigarettes are already on the table. Marijuana is more potent than it was 20 years ago. There are specific binding sites within the brain for the psychoactive ingredient, THC. There is evidence to suggest that memory can be impaired. Daily use can lead to loss of motivation and drive, poor academic performance and delays in adolescent development. A recent study suggested that these effects are reversible once smoking ceases. More study is required before accepting this conclusion. The long-term effects are not completely understood.

Quality control of illicit drugs is an issue; there is none. Users have no idea what they are about to inhale or consume. Is there pesticide residue or is it laced with other noxious substances? Drug dealers are not the pantheon of the Better Business Bureau.

Many parents face these discussions with their children. If they have never smoked pot, then they should say why they did not. One must provide logical adult reasoning. Lectures are ineffective and tend to incite a defensive reaction. Parents should engage them in thought experiments regarding the consequences of smoking-up.

If there is a past history of use it is better to come clean. Hypocrisy weakens the argument. Parents should provide reasons why they used it and why they stopped. Teens benefit from understanding what your life circumstances were at that time. They should see that they may indeed share similar life experiences.

Here are some of the questions parents might address:

Did smoking up make you paranoid?
Did your appetite cause too much weight gain?
Are you now embarrassed by the revelations you thought you had about life at that time?
Are you concerned about its effect upon your memory?
Did you lose out on potential opportunities for advancement in your professional or social life?
Why did you stop?
Did it lose its infatuation value?
Were there other life endeavours to face?
Did you replace it with any other drug?
Teens can relate to the reality of these points. It shows them that poor decisions are not confined to any one group in society. Whether parents have smoked up or not, rational discussion does not imply that illicit drug use should be condoned. Nor does it mean that the rules of the house be compromised. Notions of family honour, respect for oneself and personal responsibility are part of the fabric that serves children well. Setting rational limits for privileges and curfews helps create a balanced system that respects the child’s needs and safety with responsible behaviour. A gradual shift of control from the parent to their child as they demonstrate honourable behaviour reinforces respect and dignity.

Reflecting on our own foolishness of youth and imparting that experience upon them under the aegis of responsibility and understanding has a better chance of changing behaviour than does confrontation. Just saying no does nothing.

Teens and the weed issue

Dr. Barry Dworkin — Tue, 14 May 2002 16:31:00 +0000

Originally published in The Medical Post, VOLUME 38, NO. 19, May 14, 2002

‘Just say no’ won’t work when it comes to talking to your teenager about the dangers of smoking marijuana. Much more will be achieved with rational discussions about responsibility

You walk a fine line at times when responding to teens’ questions. One frequently asked centres around comparisons between marijuana, cigarettes and alcohol. For example, the question might be phrased as: “What is worse, smoking a joint or smoking a cigarette?”

At the outset, I do not condone the use of any drug, illicit or otherwise that compromises public safety, disrupts personal growth and development or interferes with a person’s day-to-day functioning (side-effects of necessary medications notwithstanding).

These questions can be dangerous waters. On one side, there is the parent in you who reaches for the staid paternalistic response: “Are you freaking crazy! What the hell are you thinking about?” This response does not usually win many converts.

The other side is more complex. The message must be clear, imply personal responsibility for actions and decisions, honest, respectful and challenging.

Teens know when you are feeding them a line. They want factual, truthful answers to their questions without moralizing about their actions unless they ask. They know many adults have smoked marijauna, and continue to do so. That message is clear to them. A fresh approach is needed to convey the concerns of disruptive drug use.

They know alcohol and cigarettes cause more death and suffering than all illicit drug use combined. So what is the message? Is one joint more or less harmful than one cigarette?
The smoke from a joint is held within the lungs for a longer period of time than cigarettes. More of the tar and other noxious and carcinogenic compounds settle within the lung. The difference in this case is quantity. Most cigarette smokers smoke more than one or two cigarettes a day, whereas the pot smoker may smoke a joint a day or every other week. Over the long term, cigarettes win this skirmish for physical harm hands down.

However, you do not get high from cigarettes. A joint has more potential for social and personal harm if smoked while driving, operating machinery or engaging in serious interpersonal conflict resolution. Alcohol inebriation produces similar harm.

As with any drug, context for its use is important. Are the pot smoker’s school grades suffering? Are they losing the drive and motivation to pursue their dreams and life goals? Is it thwarting their normal adolescent development? Are interpersonal relationships suffering?

Is there a difference between being drunk and being stoned? Aggression and uninhibited behaviour is more likely with the former state of inebriation. If the person is safe at home, is one drug more unacceptable than the other? If, as a society, we accept the message for responsible alcohol use, what would one say regarding marijuana if used under the same context?

What about other health risks? For the sake of argument, let us assume the dangers of alcohol and cigarettes are already on the table. Marijuana is more potent than it was 20 years ago. There are specific binding sites within the brain for the psycho-active ingredient, THC. There is evidence to suggest memory can be impaired. Daily use can lead to loss of motivation and drive, poor academic performance and delays in adolescent development. A recent study suggested these effects are reversible once smoking ceases. More study is required before accepting this conclusion. The long-term effects are not completely understood.

Quality control of illicit drugs is an issue, as there is none. Users have no idea what they are about to inhale or consume. Is there pesticide residue or is it laced with other noxious substances? Drug dealers are not the pantheon of the Better Business Bureau.

Many parents face these discussions with their children. If they have never smoked pot, then they should say why they did not. One must provide logical adult reasoning. Lectures are ineffective and tend to incite a defensive reaction. They should engage them in thoughtful experiments regarding the consequences of smoking-up.

If parents have a past history of use, I advise them to come clean. Hypocrisy weakens the argument. They should provide reasons why they used it and why they stopped.

Here are some of the questions parents might address:
• Did smoking up make you paranoid?
• Did your appetite cause too much weight gain?
• Are you now embarrassed by the revelations you thought you had about life at that time?
• Are you concerned about its effect upon your memory?
• Did you lose out on potential opportunities for advancement in your professional or social life?
• Why did you stop?
• Did it lose its infatuation value?
• Were there other life endeavours to face?
• Did you replace it with any other drug?

Teens can relate to the reality of these points. It shows them poor decisions are not confined to any one group in society.

Whether parents have smoked up or not, rational discussion does not imply illicit drug use should be condoned. Nor does it mean the rules of the house be compromised. Notions of family honour, respect for oneself and personal responsibility are part of the fabric that serves children well. Setting rational limits for privileges and curfews helps create a balanced system that respects the child’s needs and safety with responsible behaviour. A gradual shift of control from the parent to their child as they demonstrate honourable behaviour reinforces respect and dignity.

Reflecting on our own foolishness of youth and imparting that experience upon teens under the aegis of responsibility and understanding has a better chance of changing behaviour than does confrontation.

Just saying no does nothing.