In a few weeks, hordes of world’s media will descend on Vancouver, British Columbia for the 2010 Winter Olympic Games. The most intrepid journalists will grab a camera man and head down to Vancouver’s Downtown Eastside (DTES) to get their money-shot: a homeless person sleeping on a heating vent, or a drug user shooting-up in Blood-Alley. Then they will roll out the sad-but-true statistics to contrast the majesty of the snow-capped North Shore mountains with the human misery of Canada’s worst slum. This will be broadcast around the globe for billions to see. There will be gnashing of teeth and wringing of hands, as Canadians are forced to explain the horrors lurking on their doorstep.
However, in the wake of this social catastrophe, there are rays of hope. The local, federal and provincial governments have poured hundreds of millions of dollars into the area over the past decade in an effort to keep this from being cast as a totally bad-news story.
Duncan Sallie, cleaning up
This weekend’s Globe and Mail ran a two page story on Duncan Sallie, an ex-squeegee kid, and his quest for employment on the DTES. Mr. Sallie is a 26 year old homeless man with a checkered past, few marketable skills, years lost to drug-addiction and a history of mental illness. Yet, he showed up to his first job interview wearing a clean shirt and big smile.
One of the stories within the story is the success of BOB (Building Opportunities with Business) a government funded agency which provides unconventional services to the city’s neediest and hardest to employ, resulting in real jobs for 137 inner-city residents, like Duncan Sallie, since October 2008.
Mr. Sallie is an ex-crack addict with a rebellious and violent past. As a child, before taking drugs, he was diagnosed with Attention Deficit Hyperactivity Disorder. Although the story does not specify the details, it is a story that I hear in my office, every day.
Young men like Mr. Sallie have a frighteningly common trajectory. The movie goes something like this…
As a child, he was a charming and energetic boy, who did not like to read and had difficulty sitting still. He was a daredevil, risk taker, good at sports, but bored in school. He may have been raised in a loving home, and may even have done well in school, initially. But his quirks get him rejected by the popular students and invariably he falls in with the wrong crowd. He starts smoking and drinking early. He quickly graduates from smoking to “blazing”, but he does not graduate from high school. Smoking pot starts off as a way to ease the boredom or to be cool, but eventually becomes a daily ritual. If smoking pot is as far as this young man’s drug taking ever goes, the story may be a downer, but it’s not a tragedy.
In order to have a truly tragic ending, he needs to move on to more adventurous experimentation with mushrooms, acid, speed, ecstacy and/or cocaine…. And, he does. Again, while snorting cocaine may leave you in debt, it does not usually leave you homeless. In order to win that distinction, you usually have to tangle with one of the three home-wreckers: crack, alcohol or heroin.
If you want to see homelessness, live and in colour, go down to the DTES. Stand on the corner of Main and Hastings and the sights will break your heart. Homelessness is not caused by lack of money. Every day more money changes hands in the DTES than on the Vancouver Stock Exchange. Homelessness is not caused by mental illness per se. It is caused by the executive dysfunction and impulsivity that is associated with certain types of mental illness including substance abuse and addiction. Can’t get a job; can’t hold a job; can’t pay the rent; go on disability, get housing assistance, but get kicked out for doing drugs or beaking off to the landlord.
Mr. Sallie is trying to change his lot in life. Currently, he is on methadone, prescribed by an addiction specialist in Vancouver. It keeps him away from the needle and allows him to focus on getting a job. But even though 10 doctors will have seen ADHD on his chart at various hospital or clinic admissions, no one will have taken it upon themselves to treat it.
There are some good and practical reasons to be wary of treating ADHD in a person with an active addiction, but the experts agree, it’s not a deal breaker. All the research shows that the risk of treating ADHD, even in the actively addicted, can be managed. The problem is, as in the case of Duncan Sallie, the diagnosis is made and an initial treatment is prescribed, but there are not enough skilled clinicians to provide patient education, follow-up or ongoing treatment for those who go on to manifest ADHD as adults.
There were 1000 adults on the waiting list at the only adult ADHD facility in British Columbia. The BC government wanted to shorten the waiting list, so they closed the program. They pay for the risky, short acting, addictive stimulants, but they do not cover the cost of the safer, non-addictive, slow release stimulants. Go figure. They think they are saving money.
The hallmarks of ADHD are executive dysfunction and impulsivity. A number of recent studies have documented how frequent ADHD is in homeless men. A few years ago, the Mayor of Vancouver, Sam Sullivan tried to start a program of treating cocaine and methamphetamine addiction with “replacement therapy”. It was not a bad idea. If stimulant abusers were addicted to fast-acting stimulants, maybe we could wean them off their drug of choice by using slow-acting stimulants. The same principle is used in replacing heroin addict’s fast-acting opioids with slow-acting opioids (methadone). Sullivan’s wish to get replacement treatment on the street before the Olympics was innovative and plausible with some adjustments, but it met with significant resistance from various stakeholders and the plan died on the vine.
A more rationale idea would have been to screen homeless stimulant abusers for ADHD and, within the risk management guidelines alluded to above, treat their impulsivity and executive dysfunction. Duncan Sallie would likely, in my opinion, have benefitted.
Mr. Sallie showed up to his job interview on time, but at the last minute, he realizes that he has forgotten to put together a resume. He sits down to write one, but he is so nervous and so fidgety, that he spills coffee on his new pants. We don’t know for sure why he does not get the job, but we’re not given any reason to be particularly optimistic.
Last May, I presented a paper at the 2nd International Congress on ADHD in Vienna, Austria. “Management of ADHD in patients with co-morbid cocaine addiction”. To make a long story short, the study which included 53 patients, showed that those cocaine users whose impulsivity was pre-treated with a mood-stabilizer (which inhibits glutamate, increases GABA. or both) before their executive function was treated with ADHD medications, had significantly better outcomes than those who received ADHD treatment without a mood stabilizer. It’s a preliminary study,not yet replicated, and as yet unpublished, but there is a signal there. It is an outcome that I see every day in my practice…
Treat the impulsivity first (by modulating Glutamate and GABA), then treat the executive dysfunction (by boosting Dopamine) and the patient’s function will improve. Here are a few quotes from one the patients in the study….
“I still have ups and downs, but I feel more on an even keel. I can deal with things better. I can listen. I can go to a meeting and actually follow. I can take care of children and really be attentive. It’s amazing”.
“I don’t feel as aggressive. I don’t want to throw stuff, kill people, or kill myself. I’m not as violent. I don’t fly into rages anymore. I don’t seem to have nearly as many cravings. I can concentrate better. I can actually read three chapters. That’s a big improvement.”
I don’t know whether this kind of intervention could have helped Mr. Sallie’s chances of making a comeback. What is important is that his story has been told and that the people following the Olympics realize that with with the right resources and a little political will, homelessness can be be beaten.
Dr. Anthony Ocana MSc, MD, CCFP, ABAM Family Physician/ Addiction Medicine Specialist firstname.lastname@example.org