May 2021: 63:4 Self-poisoning among Pages 145–192 British Columbian children and youth Demographic and geographic characteristics

IN THIS ISSUE Endometriosis: An update on diagnosis and medical management Systemic racism and medicine: A commentary Intergenerational housing as a model for improving older- adult health Potent sedatives in opioids in BC: Implications for resuscitation, and benzodiazepine and etizolam withdrawal

bcmj.org May 2021 Volume 63 | No. 4 Pages 145–192

Beyond the direct effects of improving the health of older adults, intergenerational housing can lead to beneficial outcomes for society as a whole. Article begins on page 171.

The BCMJ is published by Doctors of BC. The journal provides peer-reviewed clinical and review articles written primarily by BC physicians, for BC physicians, 148 Editorials 151 President’s Comment along with debate on medicine and medical politics in editorials, letters, and essays; BC medical news; career Pandemic musings Mass disruption: A time of great pain and CME listings; physician profiles; and regular columns. David R. Richardson, MD and great hope, Matthew C. Chow, Print: The BCMJ is distributed monthly, Research ethics board approval: MD other than in January and August. What, why, when, how? Web: Each issue is available at www.bcmj.org. 152 Premise Subscribe to print: Email [email protected]. Caitlin Dunne, MD Single issue: $8.00 Systemic racism and medicine: Canada per year: $60.00 150 Letters A commentary, Christopher O.Y. Foreign (surface mail): $75.00 Re: Benefits and limitations of Li, BSc, Daljeet Chahal, MD, Trana Subscribe to notifications: To receive the table of contents by email, visit ultrasound in diagnosis of rib Hussaini, PharmD, Eric M. Yoshida, www.bcmj.org and click on “Free e-subscription.” fractures, Mike Figurski, MD MD Prospective authors: Consult the “Guidelines for Authors” at www.bcmj.org 150 Obituaries 156 Council on Health Promotion for submission requirements. Dr Muhammad “Max” Zahir The brewing issue in kombucha Lloyd Oppel, MD

On the cover Editor Managing editor Proofreader Printing Self-poisoning is a significant and David R. Richardson, MD Jay Draper Ruth Wilson Mitchell Press growing problem, particularly Editorial Board Associate editor Web and social media Advertising for BC children and youth. The Jeevyn Chahal, MD Joanne Jablkowski coordinator Tara Lyon exceptionally high self-poisoning David B. Chapman, MBChB Amy Haagsma 604 638-2815 rates among females age 10 to 19 Editorial and production Brian Day, MB [email protected] are striking, which is consistent coordinator Cover concept and Caitlin Dunne, MD with research that has found Tara Lyon art direction, Jerry Wong, ISSN: 0007-0556 David J. Esler, MD higher self-poisoning rates among Peaceful Warrior Arts Established 1959 Yvonne Sin, MD Copy editor female youth compared with Cynthia Verchere, MD Tracey D. Hooper Design and production males. Article begins on page 164. Laura Redmond, Scout Creative

146 BC Medical Journal vol. 63 no. 4 | May 2021 CLINICAL

158 Endometriosis: An update on diagnosis and medical management, Giselle Hunt, BSc, Catherine Allaire, MD, Paul J. Young, MD, Caitlin Dunne, MD 164 Self-poisoning among British Columbian children and youth: Demographic and geographic characteristics, Samantha Pawer, BSc, Fahra Rajabali, MSc, Jennifer Smith, BFA, Alex Zheng, MSc, Anand Dhatt, Roy Purssell, MD, Ian Pike, PhD 171 BCMD2B Intergenerational housing as a model for improving older-adult health Raiya Suleman, BHSc, Racism and discrimination are deeply ingrained in our society and represent significant social determinants of health— Faizan Bhatia, BHSc a truth that is backed by a growing body of evidence that highlights disparate health outcomes in racial minorities. Article begins on page 152. 176 Joint Clinical Committees

A first-of-its-kind Canadian 179 WorkSafeBC n partnership for a stronger health care Learn about potential billing issues Medical advisors reaching out to early; check out your mini profile system, Ahmer Karimuddin, MD, n Anthon Meyer, MD community physicians: A new Improvements to Rural Retention WorkSafeBC initiative, Janice Program encouraging physicians to 177 BCCDC Mason, MD, Alfredo Tura, MD, practise in rural communities n Potent sedatives in opioids in BC: Peter Rothfels, MD Fast-tracked vaccinations for the Implications for resuscitation, vulnerable: Communicating with 180 News patients and benzodiazepine and etizolam n 2020 MacDermot writing prize withdrawal, Roy Purssell, MD, 184 CME Calendar winners Jane Buxton, MBBS, Jesse Godwin, n Doctors of BC insurance team MD, Jessica Moe, MD 186 Guidelines for Authors working remotely to support your needs, Kerri Farrell 188 Classifieds

Environmental impact Postage paid at Vancouver, BC. Canadian Publications Mail, Product Sales Agreement #40841036. Return undeliverable copies The BCMJ seeks to minimize its negative impact on the to BC Medical Journal, 115–1665 West Broadway, Vancouver, BC V6J 5A4; tel: 604 638-2815; email: [email protected]. environment by: Advertisements and enclosures carry no endorsement of Doctors of BC or BCMJ. • Supporting members who wish to read online with an e-subscription to bcmj.org © British Columbia Medical Journal, 2021. All rights reserved. No part of this journal may be reproduced, stored in a retrieval system, or trans- • Avoiding bag use, and using certified-compostable plant-based mitted in any form or by any other means—electronic, mechanical, photocopying, recording, or otherwise—without prior permission in bags when needed writing from the British Columbia Medical Journal. To seek permission to use BCMJ material in any form for any purpose, send an email to • Working with Mitchell Press, ranked third in North America for [email protected] or call 604 638-2815. sustainability by canopy.org Statements and opinions expressed in the BCMJ reflect the opinions of the authors and not necessarily those of Doctors of BC or the • Printing with vegetable-based inks institutions they may be associated with. Doctors of BC does not assume responsibility or liability for damages arising from errors or omis- • Using FSC-certified paper sions, or from the use of information or advice contained in the BCMJ. • Printing locally in British Columbia The BCMJ reserves the right to refuse advertising.

BC Medical Journal vol. 63 no. 4 | May 2021 147 Editorials

Pandemic musings

6 April 2021

s this pandemic continues into its learned that gunshot deaths climbed during The coronavirus pandemic has drawn sig- second year, it is hard to be cheerful 2020. nificant attention and effort to fight it. Measures and optimistic. In terms of silver lin- According to the Gun Violence Archive, include regular briefings from the provincial ings,A 2020 was likely a far better year for the about 45 000 Americans died of gun violence health officer and health minister along with a environment. Climate change shifted into a in 2020 compared to roughly 40 000 in 2019. mobilization of public health and health region lower gear and nature was able to take a deep In fact, shooting deaths in resources. The population breath. Many large industrial centres noted 2020 outpaced the next About 45 000 has tolerated previously less smog with improved views, and many wa- highest recent year (2017) Americans died of gun unheard of restrictions terways were blessed with the reappearance of by more than 3600. Last with minimal complaint. fish and whales. year, the United States violence in 2020. I wonder what could be The recent run of mass shootings in the noted the highest 1-year accomplished if similar ef- United States reminded me that these previ- increase in homicides forts were directed toward ously common events were seldom spoken of since they started keeping records. the often-marginalized population of people in 2020. I took comfort, thinking that per- Some claim that this is not a gun problem who use drugs and the overdose crisis. haps the pandemic has also led to reduced gun but a mental health issue. However, recently a Forgive me for my pandemic musings, but violence for our southern neighbors. Imagine man went on a rampage with a knife in North this challenging time lends itself to reflection, my surprise when I researched the topic and Vancouver, stabbing multiple victims and end- and with that a desire for seeking hope amid the ing one woman’s life. I would argue that if this ruin. Sadly, we won’t find any uplifting change obviously disturbed individual had access to when it comes to gun violence and illicit drug an assault rifle the toll would have been much deaths. n Secure cloud-based clinical higher. —David R. Richardson, MD COVID-19 mobilized the world, and the speech recognition United States has been a leader in developing a vaccine to combat the pandemic. Imagine Doctors Dictate into your EMR from what could be accomplished if a fraction of the almost anywhere resources devoted to combating a virus were Helping directed toward ending gun violence. Doctors Install within minutes across One fact that is often overlooked is that 24 hrs/day, unlimited computers gun violence is a male problem. When was the last time you heard about a woman going 7 days/week One synchronized user on a shooting rampage with a semiautomatic profile weapon? Mass shooters are predominantly men If something is on your mind, Stunningly accurate with who turn to violence as a means of solving some internal strife. Men must do better and learn give us a call at accents to control their emotions without resorting to 1-800-663-6729. Or for more acts of aggression. information about our services, Contact us today for a free trial! Lastly, before we feel too smug here in Can- visit www.physicianhealth.com. 604-264-9109 | 1-888-964-9109 ada, and specifically in our home province, we should look at another local epidemic. In 2020

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148 BC Medical Journal vol. 63 no. 4 | May 2021 Editorials

Research ethics board approval: What, why, when, how?

t the BC Medical Journal, we often of Canada’s three federal research agencies.5 How can researchers obtain ethics receive submissions from clinicians Applications to UBC’s REBs require all team approval? who want to share their findings, but members to have completed a tutorial on the Research ethics boards have a standardized ap- 6 theyA aren’t sure how to approach the subject of Tri-Council Policy Statement. The key prin- plication process. UBC uses an online platform research ethics. Here is a brief summary for our ciple is informed consent, where research par- called Research Information Systems (RISe) readers and prospective authors. ticipants are fully informed about the potential to track applications, amendments, and an- risks and benefits of the study. nual renewals. Ethics boards generally allow What is a research ethics board? for two levels of review depending on the type Research ethics boards (REBs) are “autonomous When does a study need research of study: delegated review (subcommittee re- entities whose primary responsibility is to pro- ethics board approval? view of studies deemed minimal risk) and full tect the rights and welfare of human partici- In Canada, any research study involving hu- review (anything beyond minimal risk). The 1 pants taking part in research.” They can also man participants, human tissue, or human data timeline for review and approval can vary due help to ensure that research is of high quality requires research ethics board approval before to committee schedules and the number of 2 and is clinically important. The University of commencement. If you are undertaking a quali- revisions required, but it may take anywhere British Columbia has several such boards, in- ty improvement project, it does not require REB from days to months. Researchers affiliated cluding Children’s and Women’s, BC Cancer, oversight. However, it is important to note that with UBC can get started at www.rise.ubc.ca/ Providence Health Care, and the UBC Clini- REBs cannot review research that has already guidance-notes-and-tutorials. n cal Research Ethics Board. These committees been done; if there is any doubt about your proj- —Caitlin Dunne, MD, FRCSC are composed of individuals from varied back- ect constituting research, it is best to consider grounds such as physicians, scientists, research- the intention of the project before beginning. Acknowledgments ers, ethicists, and community members. There A sorting tool, available on the PHSA website, Dr Dunne would like to thank Ms Jennie Prasad and are also private for-profit ethics boards, which can be a helpful first step (https://rc.bcchr.ca/ Dr Marc Levine of the BC Women’s and Children’s adhere to the same principles and are selected redcap/surveys/?s=HNWAAKFF97). If re- Hospital Research Ethics Board for their editorial by some researchers for expediency or if the search ethics appear to be required or you are input on this article. researchers are not affiliated with a university. uncertain, contact your local REB. At the BCMJ, we also receive submissions References Why is research ethics approval of quality improvement projects that have 1. UBC Office of Research Ethics. UBC clinical research ethics general guidance notes. Accessed 22 March necessary? been written up for publication. For example, 2021. https://ethics.research.ubc.ca/ore/ubc-clinical- Involuntary studies on human subjects in the past a medical student was supervised by an attend- research-ethics-general-guidance-notes#A1. have had horrendous consequences. The Nurem- ing physician to perform a review of treatment 2. Hyer CF. What is an IRB, why do we need it, and what berg trials exposed the “scientific” evils of the times for different diagnoses in the emergency is a private IRB? Foot Ankle Spec 2010;3:91-94. 3. Shuster E. Fifty years later: The significance of the Nazi regime and resulted in the creation of the department. This study represents a retrospec- Nuremberg Code. N Engl J Med 1997;337:1436-1440. 3 Nuremberg Code in 1947. Unfortunately, around tive chart review, which involved collecting pa- 4. World Medical Association. World Medical Associ- the world, including in North America, there tient data, de-identifying the information, and ation declaration of Helsinki: Ethical principles for were many subsequent occurrences of atrocities analyzing the results. Depending on the nature medical research involving human subjects. JAMA 2013;310:2191-2194. committed in the name of research. The World and specifics of the project, the BCMJ may ask 5. Canadian Institutes of Health Research, Natural Sciences Medical Association Declaration of Helsinki the principal investigator to seek confirmation and Engineering Research Council of Canada, Social (1964, last updated 2013) was created to further from a local REB that the project was, in fact, Sciences and Humanities Research Council. Tri-Council address the ethics and safety of human research quality improvement and, therefore, did not re- policy statement ethical conduct for research involving 4 humans. 2018. Accessed 21 March 2021. https://ethics. and its application to special populations. quire REB oversight. If the research would have gc.ca/eng/documents/tcps2-2018-en-interactive-final. Today, the standards for research involv- required REB approval, it cannot be granted pdf. ing humans adhere to the Tri-Council Policy retrospectively; therefore, the submission would 6. Panel on Research Ethics. TPS2: CORE – tutorial. Ac- Statement (TCPS2 2018), which is a product not be accepted for publication. cessed 21 March 2021. http://tcps2core.ca/welcome.

BC Medical Journal vol. 63 no. 4 | May 2021 149 Letters to Obituaries We welcome original tributes of less than 500 words; we may edit them for clarity and length. Obituaries may be emailed the editor to [email protected]. Include birth and death dates, full name and name We welcome original letters of less deceased was best known by, key hospital and professional affiliations, relevant than 300 words; we may edit them biographical data, and a high-resolution head-and-shoulders photo. for clarity and length. Letters may be emailed to journal@doctorsofbc. ca, submitted online at bcmj.org/ Dr Muhammad “Max” Zahir In 1967, soon after completing his PhD, submit-letter, or sent through the Max joined the faculty at the University of post and must include your mailing 1936–2021 Maryland as an assistant professor of medi- address, telephone number, and cine. However, the pressure associated with the email address. Please disclose any academic publish-or-perish lifestyle prompted competing interests. a move to New Brunswick, where he joined the medical staff at the Moncton Hospital. The bit- ing cold winters were not always easy to navi- Re: Benefits and limitations of gate, and a move to British Columbia followed ultrasound in diagnosis of rib in 1974. A 28-year career with the Pathology Department at Royal Inland Hospital was the fractures highlight of his decorated career. Thanks for an excellent article, Dr Watson During the latter part of his tenure at Royal [BCMJ 2021;63:75-78,82]. In Big White, BC, Inland Hospital, Max held the position of chief On 20 March 2021, Dr Max Zahir continued we have about two suspected rib fractures per of pathology. This experience led him to partake his journey into new realms. Symbolically, our day. We ultrasound everyone at point of care, in a number of outside affiliations, including beloved Max left us as we ushered in the first and get X-rays if positive (to rule out pneumo/ 5 years of service as president of the Society day of spring. The finality of his passing was hemo), high clinical suspicion, or prolonged of Specialist Physicians and Surgeons of BC met with the dawning of rebirth. symptoms (indirect compression tenderness (1993–1998), as well as chair of the Laboratory Max graduated from King Edward Medical or unable to accomplish three pushups by day and Nuclear Medicine Subcommittee for the College in Lahore, Pakistan, and as top graduate three). Everyone with a confirmed fracture is BC Ministry of Health just prior to his retire- in his year, he was awarded a prestigious Rhodes advised to avoid skiing or snowboarding for 6 ment in 2002. With any professional endeavor, Scholarship to study hematology at Oxford weeks, and I estimate the median compliance Max was lauded for his diplomacy, attentiveness, University. In 1965 he obtained a PhD with is 4 to 5 weeks. Late complications have been and unfailing leadership. a thesis titled “The Nature of Wound Healing very low (none observed in about 2000 cases). A momentous retirement project was the with Special Reference to Scab Formation.” —Mike Figurski, MD publication of his memoirs in the book titled Kelowna 1947: A Memoir of Indian Independence. —Kate Zahir

Recently deceased physicians If a BC physician you knew well is recently deceased, please consider submitting an obituary. Include the deceased’s dates of birth and death, full name and the name the deceased was best known by, key hospital and professional affiliations, relevant biographical data, and a high-resolution photo. Please limit your submission to a maximum of 500 words. Send the content and photo by e-mail to [email protected].

150 BC Medical Journal vol. 63 no. 4 | May 2021 president’s comment

Mass disruption: A time of great pain and great hope

ou’ve probably heard the term collec- and fear, while at the same time triggering Mass disruption in health care has also in- tive trauma (a traumatic event shared self-reflection, innovation, and change. It is a terrupted the old ways of doing things. In the by a group of people) being used to term that encompasses the good and the bad, span of weeks, we went from less than 10% to Ydescribe the COVID-19 pandemic. I often the injurious and the healing, the fatiguing and more than 90% of medical visits taking place use this term myself. As a specialist in mental the motivating. I suggest using the term mass virtually. That number has dropped since we health, and as a child of parents who experi- disruption to describe this unique time in our adapted to pandemic conditions and found a enced homelessness and abuse, trauma is a history. better balance between virtual and face-to-face familiar phenomenon for me, professionally The word disruption describes the rupture care, but it will never fall to prepandemic lev- and personally. But trauma carries different of our social connections, restrictions put on els. Health care is one of the last industries to meanings for different people. For some, trau- our usual ways of coping with stress, and the see disruptive innovation brought on by the ma means broken bones and ruptured organs. negative impacts on our economic security. Internet age. The pandemic is exacting a heavy For others, it is a multigenerational experience It can also describe the collective awakening toll, but it is also triggering changes that will of racism and oppression. And for others still, that has triggered global movements to com- resonate for decades. it stems from everyday experiences such as bat systemic racism, gender-based violence, On occasion, you’ll still catch me calling the being called by the wrong pronoun or being and inequality—movements that have gained experience of the past year a collective trauma; told that you have dressed too provocatively. considerable momentum in spite of pandemic many people and some groups have certainly Collective trauma suggests that we have all been restrictions. It should come as no surprise that had a traumatizing experience. But more than injured in some way, which isn’t necessarily a prohibition on social gatherings, while nec- that, we have experienced a mass disruption to true of the pandemic. essary to save lives, has not impeded these our way of life, our way of coping, our way of That’s not to say people haven’t suffered; we calls for change. The need for human dignity doing business, and even our way of thinking. have seen far too many deaths; too much illness, is universal. A mass disruption need not be a negative ex- isolation, and loneliness; and too many racist In health care, this mass disruption has perience. History is full of examples of how dis- attacks and lost jobs. There are some who have meant that some colleagues have and will ex- ruption can be the impetus for positive change. fared well, at least economically, during the pan- perience problems such as anxiety, depression, The change could be personal: a look at one’s demic. Health care workers have been differen- and posttraumatic stress disorder. Doctors life goals, reconsidering one’s career, reconnect- tially affected—having to make heartbreaking of BC’s Physician Health Program has seen ing with friends and family. The change could phone calls to family members of COVID-19 record-setting demand from colleagues in dis- be organizational: taking stock of how we re- victims, hunt desperately for PPE in the initial tress. And from what we know from previous sponded to the pandemic, addressing gaps and weeks of the pandemic, and many seeing their global and regional disasters, we can anticipate shortcomings, doing better next time. Or the practices and operating rooms closed due to this demand to continue increasing, peaking change could be global: awakening to the reali- pandemic restrictions. Again, there are some as much as a year or more after the pandemic ties faced by disadvantaged and marginalized who were able to make a swift move to virtual before subsiding. We know that some of our groups, highlighting the interconnectedness of care, and some have not seen a single case of patients, especially those who have been person- nations, and motivating one another to build COVID-19. ally affected by COVID-19 or who have had a better world. Sometimes we need to use different termi- protracted courses of illness, will continue ex- COVID-19 has created a mass disruption n nology to avoid preconceived ideas and experi- periencing challenges long after the last person for us all, but we choose how to respond. ences associated with certain words. That’s why is vaccinated. We saw this with SARS in 2003, —Matthew C. Chow, MD I use a different term to describe what has led MERS since 2012, and myriad other outbreaks Doctors of BC President us to experience so much fatigue, frustration, of disease around the globe.

BC Medical Journal vol. 63 no. 4 | May 2021 151 Premise

Systemic racism and medicine: A commentary

A reflection on historical mistakes that we must recognize and learn from to catalyze positive change.

Christopher O.Y. Li, BSc, Daljeet Chahal, MSc, MD, FRCPC, Trana Hussaini, PharmD, Eric M. Yoshida, OBC, MD, MHSc, FRCPC

he year 2020 was fraught with tragic probably represent the tip of the iceberg; many While physicians and other health care workers events that brought social injustices incidents most likely go unreported to authori- are committed to providing the best care and into the spotlight worldwide. Follow- ties or the media. treating all patients equally, systemic racism ingT the deaths of George Floyd and Breonna These incidents are rooted in institutional- exerts its effects subconsciously and insidiously. Taylor, directly due to the actions of local police, ized and societally accepted racism that goes The 1932 Tuskegee Study serves as a historic and what can only be described as the racially back centuries. The legacy of slavery and the example of the ideological effects of systemic targeted killing of Ahmaud Arbery, the Black long-standing Jim Crow laws in the United racism in academic medicine, which allowed for Lives Matter movement gained significant mo- States, and the govern- this shameful experiment mentum in the United States, and with it, calls ment sanctioned, en- Treating patients the to take place in the name to address the enduring inequities rampant in forced residential school of medical science and modern society. But social injustice and racism system imposed on Ca- same or equally does not the “greater good.” In this are not restricted to the United States. This nadian Indigenous com- imply equity; doing so study, 600 African Ameri- year alone saw the brutal recorded assault of munities, have created ignores the disparities can men from Alabama, Indigenous Chief Allan Adam at the hands of social-economic inequi- that have existed 399 of whom had syphilis, police in Alberta; the fatal and independent ties and multigenerational were enlisted to partake in shootings of two young Indigenous people, trauma. Social injustice af- for generations and an experiment intended to Rodney Levi and Chantel Moore, by police in fects individuals beyond continue to exist today. observe the natural his- New Brunswick; and the recent recorded evi- those of African or Indig- tory of untreated syphilis dence that Indigenous patient, Joyce Echaquan, enous background, and is in Black populations. The endured appalling racist and insulting com- not limited to racial inequity; other groups in- study was conducted without the benefit of ments from health care professionals as she cluding women and the LGBTQ community patients’ informed consent, and participants was dying in a Quebec hospital. These Cana- similarly continue to face discrimination and were simply told that they were receiving treat- dian incidents were covered by the media but bias. ment for “bad blood”—a colloquial term used The World Health Organization defines to describe syphilis, anemia, fatigue, and other social determinants of health as “the conditions ailments. Individuals who enlisted in this study Mr Li is a fourth-year medical student in in which people are born, grow, live, work, and over its course of 40 years were given ineffective the Faculty of Medicine at the University age.” Although these circumstances exert their medicines and denied proper treatment. The of British Columbia. Dr Chahal is a fellow effects on the individual, they are shaped by study is blamed for significantly impacting the in the Division of Gastroenterology at structural phenomena. Slavery and colonialism willingness of Black individuals to participate the University of British Columbia. Dr in the US and Canada has produced a legacy in medical research today. It is estimated that Hussaini is a pharmacotherapy specialist of racism, injustice, and brutality that pervades the life expectancy of Black men also fell by up in the Faculty of Pharmaceutical Sciences medicine as it does all social institutions. Rac- to 1.4 years following the release of the study’s at the University of British Columbia. Dr ism and discrimination are deeply ingrained details, in part due to a seeded mistrust in the Yoshida is a professor in the Division of in our society and represent significant social health care system that remains today.1 Gastroenterology at the University of determinants of health—a truth that is backed One contemporary study2 showed that British Columbia. by a growing body of evidence that highlights Black patients are more likely to trust and heed disparate health outcomes in racial minorities. the advice of Black physicians compared to This article has been peer reviewed.

152 BC Medical Journal vol. 63 no. 4 | May 2021 Premise

physicians of a different race. The researchers As in America, Canadian academic medi- The lasting effects of systemic racism result- estimated that Black physicians could reduce cine contains examples of unethical research ing in inequity are reflected in current health the cardiovascular mortality gap between Black and poor treatment of minority groups. Ian data. Indigenous people are among the high- and White patients by 19%, but Black patients Mosby3 recently brought to light the series est risk groups for developing diabetes and have a much lower chance of finding a racially of nutrition research experiments on approxi- its complications, and are overrepresented concordant physician compared to White and mately 1000 Canadian Indigenous children in HIV, tuberculosis, and sexually transmit- Asian American patients. At the same time, that took place between 1942 and 1952 across ted infection cases. The stroke rate is nearly ethnicity cannot be ignored in medicine. Treat- six residential schools. These experiments were twice in the Indigenous population compared ing patients the same or equally does not imply initiated to investigate the effectiveness of vari- to non-Indigenous Canadians, and the suicide equity; doing so ignores the disparities that ous nutritionally fortified foods in the diets rate among Indigenous youth is 5 to 7 times have existed for generations and continue to of Indigenous people after widespread hun- higher than in their non-Indigenous peers. exist today. Recent calls for ethnically inclusive ger and malnutrition in Canadian residential Today, safeguards exist to protect the medical education have been made after atten- schools was noted in the early postwar period. well-being and rights of those who volunteer tion was brought to the fact that darker skin Groups of malnourished children were denied for medical research, and they are enforced by tones are underrepresented in images showing adequate nutrition while others were fed food institutional research ethics boards. This does dermatological manifestations of disease. In the formulas deemed illegal for sale to the gen- not, however, alleviate the mistrust felt in af- wake of COVID-19, which is disproportion- eral public due to violation of food adultera- fected communities that was created by deplor- ately affecting communities of color, physical tion laws. Some groups were even subjected able research efforts of the relatively recent past. findings such as the “COVID toes” rash have to supplement regimens of vitamins alone in Today, it is generally accepted that research been presented in medical literature only in order to observe the physical manifestations involving the Indigenous community must be individuals with a lighter skin color. of malnourishment. done in consultation with representatives of

BC Medical Journal vol. 63 no. 4 | May 2021 153 Premise the community, the outcomes of the research manage overt bigotry safely and educate our must be available for dissemination to the com- peers on how to do the same. All instances of munity, and the research must be of potential discrimination, bias, prejudice, and ignorance benefit to the community. that arise should be firmly rejected. Finally, we must continue to plant the What can we do? seeds of change so that our Subconscious bias can BC Medical Journal As health care profes- efforts are not short-lived. Follow sionals, we interact with subtly influence how Educators must continu- @BCMedicalJrnl individuals from all eth- we interact with others ously evaluate their learn- The BC Medical Journal provides continuing medical education through scientific research, nicities, genders, religions, and how we, in turn, ing materials and develop and social backgrounds. curricula that ensure equal review articles, and updates on contemporary clinical practice. #MedEd We play a direct role in are treated, all without representation of all peo- the type of care they re- us realizing its effects. ple for all levels of medical In Plain Sight: Elaboration on the ceive, and, in doing so, education. Our medical review. The authors discuss the review directly influence their schools should continue to on #Indigenous-specific #racism and health outcomes. Therefore, we first have an promote cultural sensitivity and encourage fu- #discrimination in BC health care. individual and collective responsibility to un- ture physicians to practise and model tolerance, n Read the special feature: bcmj.org/ derstand the roots of contemporary health respect, kindness, and open-mindedness. special-feature/plain-sight-elaboration disparities so that we can fight the systemic -review racism that exists. Next, we must define and References 1. Corbie-Smith G. The continuing legacy of the Tuske- understand what racism is. Racism can present gee Syphilis study: Considerations for clinical investi- in many ways, and it is not limited to the bla- gation. Am J Med Sci 1999;317:5-8. tant events seen in the media. Perhaps its most 2. Alsan M, Garrick O, Graziani G. Does diversity matter dangerous form is subconscious bias, which can for health? Experimental evidence from Oakland. Am Econ Rev 2019;109:4071- 4111. subtly influence how we interact with others 3. Mosby I. Administering colonial science: Nutrition re- and how we, in turn, are treated, all without us search and human biomedical experimentation in realizing its effects. To overcome this, we must Aboriginal communities and residential schools, 1942- be conscious of our interactions and carry an 1952. Histoire Sociale/Social History 2013;46:145-172. open and willing attitude to identify and con- Follow us on Twitter for regular updates trol our implicit biases. We must also learn to

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154 BC Medical Journal vol. 63 no. 4 | May 2021 VACCINE INFORMATION TOOLKIT Support for conversations about the COVID-19 vaccine

As BC’s Immunization Plan rolls out across the province, your patients are likely to turn to you as a trusted source of information around COVID-19 vaccines. To help you in your conversations with patients, we’ve developed a vaccine information toolkit that includes posters, patient handouts and links to more resources. Visit doctorsofbc.ca/toolkit.

@doctorsofbc @ bcsdoctors @doctorsofbc doctorsofbc.ca BC Medical Journal vol. 63 no. 4 | May 2021 155 coHp

The brewing issue in kombucha

What is kombucha? contains alcohol. In Canada, the ethanol con- What do we do now? Kombucha is a popular fermented black or tent of a beverage must be below 1.1% in order The BC Centre for Disease Control’s recent green tea that attracts customers with its unique for it to not be regulated as an alcoholic bever- study into this issue5 recommends that: mix of fruity and sweet-and-sour flavors, prom- age. (In the US, beverages must be below 0.5% • Labeling must clearly indicate alcohol ises of low sugar content, and a variety of alleged ethanol content.) Yet kombucha is a fermented content. health benefits. Kombucha appeared as early as product, and although ethanol production is • Alcohol content must be at or below 1% for 2000 years ago in China and Tibet, but only much diminished once the drink leaves the the shelf life of the product. made its way to the West via repatriated Rus- factory and is refrigerated, the production of • Consumers be clearly informed to keep the sian prisoners after World War I.1 beverage refrigerated. Hopefully, regulators will act to ensure that This ability of kombucha Kombucha is gaining popularity kombucha stays in the market in a way that Sales approached US$1 billion in the United to have increased minimizes risk and allows informed adults to States in 2018, and the market is projected to alcohol content after enjoy its unique flavors.n 2 reach US$6.2 billion by 2026. production has raised —Lloyd Oppel, MD concern among Is it healthy? References 1. Amir M. You can fail a breathalyzer in BC from drinking Part of kombucha’s popularity is that is has less Canadian and US kombucha, 2020. Accessed 7 March 2021. https://daily sugar than soft drinks. Another selling point is health agencies. hive.com/vancouver/fail-breathalyzer-bc-kombucha. the presence of the yeast and bacteria central 2. Lovgreen T. How much alcohol is in kombucha? BC to the fermentation process. These probiotic health officials are testing to find out. Accessed 7 March microbes are alleged to convey health benefits alcohol continues—more so at higher storage 2021. www.cbc.ca/news/canada/british-columbia/ kombucha-alcohol-testing-bc-1.5346456. ranging from antioxidant effects and anticancer temperatures and sugar content. One US in- 3. Environmental Health Services, BC Centre for Disease properties to reversing hair loss. To date, clinical vestigation found alcohol levels of 7%, higher Control. Food safety assessment of kombucha tea trials have not confirmed these claims.1,3 than that of beer.2 This ability of kombucha to recipe and food safety plan. March 2020. Accessed have increased alcohol content after produc- 7 March 2021. www.bccdc.ca/resource-gallery/ Documents/Educational%20Materials/EH/FPS/Food/ Kombucha has a secret tion has raised concern among Canadian and kombucha1.pdf. While kombucha is marketed as a health- US health agencies, the BC Centre for Disease 4. Specialty Food Association. Kombucha’s alcohol con- ful beverage,1 an inconvenient truth exists; it Control among them.3 Indeed, class action suits tent causes controversy. November 2015. Accessed 7 have been launched over false advertising of March 2021. www.specialtyfood.com/news/article/ kombuchas-alcohol-content-causes-controversy. This article is the opinion of the Environmental 4 alcohol content. 5. McIntyre L, Jang SS. A study of alcohol levels in kombu- Health Committee, a subcommittee of Doctors The situation is particularly concerning for cha products in British Columbia. 2020. Environmental of BC’s Council on Health Promotion, and is at-risk populations (including children and Health Services, BC Centre for Disease Control. Ac- not necessarily the opinion of Doctors of BC. pregnant women), as consumers may often be cessed 7 March 2021. www.bccdc.ca/resource-gallery/ Documents/Educational%20Materials/EH/FPS/Food/ This article has not been peer reviewed by the 5 unaware that there is alcohol in kombucha. Kombucha%20report%202020.pdf. BCMJ Editorial Board.

156 BC Medical Journal vol. 63 no. 4 | May 2021 ADVOCATING FOR A BETTER TOMORROW

On behalf of the profession, Doctors of BC is encouraging all British Columbians to take steps to protect themselves and others so we can all enjoy a better tomorrow.

Help spread the word by reposting our social media posts. We’ve also created a printable poster for your office and vaccine information sheets to share with patients. Get them at doctorsofbc.ca/toolkit.

@DoctorsOfBC @ BCsDoctors @DoctorsOfBC doctorsofbc.ca BC Medical Journal vol. 63 no. 4 | May 2021 157 Clinical

Giselle Hunt, BSc, Catherine Allaire, MD, Paul J. Yong, MD, Caitlin Dunne, MD Endometriosis: An update on diagnosis and medical management

A shift toward early clinical diagnosis of endometriosis, one of the most prevalent gynecological disorders, and initiation of empiric medical treatment without the need for laparoscopy is critical to improving the care and quality of life of patients who suffer from the disease.

ABSTRACT: Endometriosis is a common condi- nonspecific. A thorough history and a comprehen- Women with endometriosis may experience tion of reproductive-aged women that negatively sive assessment of a patient’s pain experience is severe pelvic pain, including dysmenorrhea, impacts their quality of life. The gold standard for recommended. A stepwise pelvic exam may reveal dyspareunia, and nonmenstrual chronic pelvic diagnosing endometriosis is direct visualization anatomic features of endometriotic implants, and pain. However, some women with endometrio- at laparoscopy; however, current guidelines sup- imaging, predominantly transvaginal ultrasound, sis are asymptomatic.4 In addition, infertility port the initiation of empiric treatment prior to can be a useful adjunct. First-line medical manage- may occur in up to 30% of women with endo- laparoscopy in patients with suspected endome- ment of endometriosis-related pain includes com- metriosis.5 Affected women may also report triosis. Clinically diagnosing endometriosis can be bined hormonal contraceptives or progestin-only fatigue, lower back pain, and urological and/or challenging because the signs and symptoms are hormone treatment. If there is no improvement gastrointestinal symptoms.5,6 These symptoms in symptoms after a 3-month trial, a referral to a are often chronic and are a major cause of dis- gynecologist is appropriate in order to consider ability and impaired quality of life because they gonadotropin-releasing hormone (GnRH) agonist, Ms Hunt is a fourth-year medical student can negatively affect women’s work productiv- GnRH antagonist, or laparoscopic treatments. In in the Vancouver Fraser Medical Program, ity, social lives, and intimate relationships, in patients with more complex disease, a referral to 7 University of British Columbia. Dr Allaire part by reducing the quality of their sex lives. the Centre for Pelvic Pain and Endometriosis at is the medical director of the Centre for Studies also suggest that there are higher rates BC Women’s Hospital and Health Centre should Pelvic Pain and Endometriosis, BC Women’s of depression, anxiety, and emotional distress be made. 7 Hospital and Health Centre, and the head in women with the condition. The direct and of the Division of Gynaecologic Specialities indirect annual costs, including health care re- and a clinical professor in the Department ndometriosis is a chronic gynecological sources and lost productivity, in Canada are 8 of Obstetrics and Gynaecology, University condition characterized by the presence estimated to be $1.8 billion. of British Columbia. Dr Yong is the research of endometrial-like tissue outside the Diagnosing endometriosis is particularly 1 director at the Centre for Pelvic Pain Euterus, and estrogen-dependent inflammation. challenging in the community setting because and Endometriosis, BC Women’s, and an It is estimated that 1 in 10 reproductive-aged it presents with a variety of nonspecific symp- associate professor in the Department of women suffer from endometriosis, making it toms that overlap with other gynecological Obstetrics and Gynaecology, University one of the most prevalent gynecological disor- and nongynecological disorders. Historically, 2 of British Columbia. Dr Dunne is a clinical ders. The extent of disease varies considerably a definitive diagnosis has necessitated surgical assistant professor at the University of from isolated peritoneal lesions to widespread removal and histological examination of tissue. British Columbia and a co-director at the pelvic adhesions, infiltrating lesions, and ovar- As a result, the diagnosis of endometriosis is Pacific Centre for Reproductive Medicine ian cysts. Most endometriotic disease is located often delayed up to 10 years after the initial in Vancouver. She also serves on the BCMJ on the pelvic peritoneum; a smaller percentage onset of symptoms, and thereby postpones ap- Editorial Board. involves the bowel, bladder, and upper abdomen. propriate treatment and causes psychological The disease rarely occurs beyond the peritoneal distress.9,10 Qualitative studies that have ex- This article has been peer reviewed. cavity (e.g., cutaneous, thoracic).3 plored other reasons for the significant delay

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Box 1. Symptoms associated with endometriosis.14,21 in diagnosis attribute it in part to normaliza- ethnicities, although there are some interesting tion of pain by both the patients and physi- differences between ethnic groups, including the • Dysmenorrhea cians and to the lack of access to specialized possibility of more severe anatomic disease in • Deep dyspareunia examinations.10,11 There is a need for further East and Southeast Asians.18 • Chronic pelvic pain education about endometriosis for both health • Cyclic dyschezia care providers and patients, with the goal of History reducing diagnostic delay by making a clinical The first step in diagnosing a woman with • Cyclic dysuria diagnosis and enhancing women’s experiences suspected endometriosis is to take a thorough • Lower back or abdominal pain of care.11-14 history, and both acknowledge and evaluate • Abnormal bleeding With the move away from a surgical diag- her symptoms. Dysmenorrhea, chronic pelvic • Fatigue nosis toward a clinical diagnosis of endome- pain, deep dyspareunia, and infertility are the • Infertility triosis, family physicians and other primary most common symptoms of endometriosis • Cyclic catamenial symptoms, including cyclic care medical professionals play an important [Box 1].5 A national case-control study of leg pain, rectal bleeding, hematuria, and dyspnea role in identifying patients earlier after devel- more than 5500 women with endometriosis opment of clinical symptoms, validating their reported that the likelihood of endometrio- concerns, and directing them to appropriate sis increased with the number of symptoms investigations or treatment. There is emerging present, from an odds ratio of 5.0 with one evidence that the early recognition and treat- symptom to 84.7 when seven or more symp- Digital palpation of posterior fornix, ment of symptoms may prevent long-term toms were present.6 adnexa, cervix, and uterus for tenderness morbidity such as chronic pain.15 This arti- The differential diagnosis for these symp- (and for nodules in the posterior fornix) cle reviews the contemporary diagnosis and toms is lengthy and includes gynecological management of endometriosis, and provides conditions such as primary dysmenorrhea, ad- information on when and how to access the enomyosis, ovarian cysts, and pelvic inflamma- BC Women’s Centre for Pelvic Pain and En- tory disease, as well as chronic pain syndromes, dometriosis to obtain specialized diagnosis including irritable bowel syndrome, interstitial Bimanual palpation for xed retroverted and treatment. cystitis, myofascial pelvic pain, and fibromyal- uterus, adnexal masses gia. These conditions may also co-occur with Pathogenesis endometriosis. In the context of persistent pain, The main hypotheses for the cause of endome- endometriosis has recently been recognized as triosis are retrograde menstruation, coelomic one of the chronic overlapping pain conditions metaplasia, and hematological/lymphatic dis- that affect mostly women and reflect a sensi- semination.1 In addition, affected women likely tization process of the central nervous system Speculum exam for invasive lesions into vagina have alterations in multiple biological pathways (central sensitization).19 that establish and support the proliferation of Asking about the temporal relationship be- this disease. These include the downregulation tween pain and the menstrual cycle may prove of apoptotic pathways and an impaired immune helpful because primary dysmenorrhea typi- Figure 1. Stepwise pelvic exam for endometriosis. response that prevents clearance of refluxed cally occurs with the onset of menstrual flow, menstrual debris, which promotes implantation is nonprogressive, and lasts approximately 8 to and growth of endometrial cells.16 Endometrio- 72 hours, while menstrual pain associated with Physical examination sis is also characterized by a positive feedback endometriosis has been described as progressive, The physical examination, which includes ab- loop between local estradiol production and cyclic, or acyclic, and it may extend beyond 72 dominal, pelvic, and in some cases rectovaginal inflammation.17 hours.20 The Society of Obstetricians and Gyn- examination, helps further refine the differen- There is a 5% to 8% increase in the risk of aecologists of Canada guidelines recommend tial diagnosis and determine the appropriate developing endometriosis in those with an af- using tools such as the patient questionnaire imaging. Digital pelvic examination should fected first-degree relative. Other risk factors provided by the International Pelvic Pain So- be performed as a single-digit palpation for include in utero exposure to diethylstilbestrol ciety (www.pelvicpain.org) for evaluating pel- tenderness [Figure 1]. Deep infiltrating endo- and longer lifetime exposure to estrogen, such vic pain. History of infertility, benign ovarian metriosis nodules (palpable thickening) may be as in early menarche or late menopause.1,17 cysts, and previous pelvic surgery are associated felt in the posterior vaginal fornix. On bimanual Historically, there has been a perception that with endometriosis, and a family history of the exam (digital pelvic exam plus abdominal palpa- endometriosis is a disease of primarily Cauca- disease should further increase suspicion of the tion together), findings suggestive of endome- sian women. However, it can be present in all diagnosis.14 triosis include a fixed, retroverted uterus, and

BC Medical Journal vol. 63 no. 4 | May 2021 159 Clinical Endometriosis: An update on diagnosis and medical management ovarian endometriomas manifesting as fixed infiltrating endometriosis, and is less operator who do not attain symptomatic relief through adnexal masses.2,21 The pelvic examination is dependent.22,24 However, MRI is considered a medical management. limited in identifying early-stage superficial dis- second-line imaging technique after TV ultra­ During laparoscopy, endometriosis is sur- ease, and normal examination findings are not sound because of higher costs and reduced gically staged, most commonly by using the sufficient to exclude endometriosis.14 Patients availability.24 Finally, while many biomark- revised American Society for Reproductive with chronic overlapping pain conditions and ers are being researched, there is currently no Medicine staging system, which classifies the central sensitization may have other findings on biomarker recommended as part of routine disease as minimal, mild, moderate, or severe examination, including bladder/pelvic floor ten- investigation of endometriosis.21 (Stage I to IV).21 Of note, surgical staging only derness on digital palpation, pelvic floor spasm, marginally correlates with severity of pain or abdominal or vulvar allodynia, abdominal wall Diagnosis risk of infertility, and an accurate diagnosis myofascial trigger points, and positive findings Current guidelines created by professional of endometriosis highly depends on surgical on examination of the back/hips. societies, including the Society of Obstetri- skill.4,5 Despite being a minimally invasive cians and Gynaecologists of Canada, state that procedure, a laparoscopy still carries a 7.5% Investigation direct visualization at laparoscopy, preferably risk of minor complications and a 1.4% risk of Transvaginal (TV) ultrasound is regarded as with histologic verification, is the diagnostic major complications.21 Most societies advocate the first-line investigational tool for suspected gold standard.20,21 However, the guidelines also a see-and-treat approach to surgery for endo- endometriosis.21 While TV ultrasound cannot advocate for medical treatment of clinically metriosis, and state that a purely diagnostic detect superficial peritoneal disease, it has a suspected endometriosis without a surgical di- surgery (without treatment at the same time) high sensitivity and specificity for the diagnosis agnosis. There has been a push by experts in the is not in the best interest of the patient. In pa- of ovarian endometriomas [Figure 2].22 The field to move away from a surgical diagnosis tients with signs of advanced disease (ovarian ability to detect deep infiltrating endometri- and toward a clinical diagnosis, where patients’ endometrioma or deep infiltrating disease), a otic lesions is shown to improve significantly symptoms and signs are emphasized.14,20 This referral to a gynecologist with expertise in surgi- when the TV ultrasound is performed by an does not diminish the value of laparoscopy as cal management of endometriosis is indicated. endometriosis specialist.23 Magnetic resonance a diagnostic tool, particularly when diagno- imaging (MRI) has high diagnostic accu- sis is uncertain. Laparoscopy is also a valuable Current treatment racy in detecting endometriomas and deep treatment option for endometriosis in women Treatment of patients with endometriosis pain may include medical therapy, surgical therapy, or both. Medical treatment is intended to reduce pain through hormonal suppression and reduc- tion or elimination of menses.1 Fertility-sparing surgical treatment aims to relieve symptoms through ablative techniques or excision of le- sions, while still conserving reproductive func- tion, and therefore, may be indicated as first-line therapy for temporary pain relief in women seeking spontaneous conception.25 The first-line treatment for women who do not wish to conceive in the near future is com- bined hormonal contraceptives or progestin- only hormone treatment, with analgesics as needed. Other hormonally suppressive treat- ment options include injectable gonadotropin- releasing hormone (GnRH) agonists plus add- back therapy, but this is generally viewed as a second-line treatment due to cost and side effects. An oral GnRH antagonist (elagolix) for endometriosis was approved in Canada af- ter promising results of the randomized con- trolled trial were published in the New England Figure 2. Transvaginal ultrasound. Endometriomas contain old brown blood, which is why they have been Journal of Medicine in 2017.26 Danazol was an referred to as “chocolate cysts.” On transvaginal ultrasound, endometriomas often display a characteristic ground glass appearance. early treatment for endometriosis; however, its

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Table 1. Common hormonal medications used for the management of endometriosis. androgenic side effects limit its clinical useful- ness, and it has now fallen out of favor. Because Type Dose these hormonal therapies have similar clinical Cyclic combined hormonal contraceptives effectiveness in treating endometriosis-related pain, patient preference, cost, and side effect Monophasic, biphasic, or triphasic pill 1 tablet/day 27 profiles are important in treatment selection. Continuous combined hormonal contraceptives

Recurrence of pain upon discontinuation limits Monophasic pill 1 tablet/day the usefulness of hormonal therapy.28 Common Progestins treatment options are summarized in Table 1. Norethrindrone 0.35 mg, 1–3 tablets/day Nonsteroidal anti‐inflammatory drugs Norethrindone acetate 5 mg, 0.5–2.0 tablets/day Nonsteroidal anti‐inflammatory drugs Dienogest 2 mg, 1 tablet/day (NSAIDs) are a common first-line treatment Depot medroxyprogesterone acetate 150 mg IM every 6–8 weeks that work by reducing the production of pros- taglandins, which are believed to be respon- Levonorgestrel intrauterine system 52 mg released over 5 years sible for causing dysmenorrhea and cramps.29 While NSAIDs effectively treat primary dys- menorrhea, a Cochrane review did not find Box 2. Tips for breakthrough bleeding.33 any high-quality evidence to support NSAID efficacy in treating endometriosis-related non- • Counsel about consistent pill use and smoking abstinence to reduce risk of breakthrough bleeding. menstrual pain.29 Despite this, NSAIDs are still • Switch to a different combined hormonal contraceptive (higher dose of estrogen or different type widely used in the management of endometrio- of progestin). ses due to their low cost, few side effects, and • Add a 7-day course of oral estrogen. ready availability; however, women should be • If on a continuous regime for ≥ 21 days, discontinue the combined hormonal contraceptive for counseled on the increased risk of gastrointes- 3 to 4 days. tinal ulceration and cardiovascular disease.28

Combined hormonal contraceptives Combined estrogen and progestin contracep- prolonged periods of time and are well tolerated. pelvic pain and dysmenorrhea in women with tives (combined hormonal contraceptives), Adverse events are generally mild and include endometriosis.34 The most common side ef- including combined oral contraceptive pills, nausea, headaches, weight changes, and mood fect with progestin-only therapies is menstrual transdermal patches, and vaginal rings, are con- changes, and importantly, a small increased cycle disturbance, which can be managed with sidered first-line treatment for endometriosis in risk of venous thromboembolism.32 The most a 10- to 14-day course of low-dose estrogen 21 women without contraindications. Combined frequent reason for discontinuing combined to counteract endometrial atrophy.28 Mood hormonal contraceptives inhibit ovulation, re- hormonal contraceptives is breakthrough bleed- changes and weight gain are also clinical con- duce menstrual flow, and cause decidualization ing or spotting, which is treatable [Box 2].32,33 cerns.35 However, progestins do not have the and atrophy of endometriosis implants, which same thrombotic risk that combined contra- 28 leads to a reduction in pain. The efficacy of Progestins ceptives have. If a patient has responded well combined oral contraceptive pills in providing Progestin-only therapies are another first-line to these endometriosis-specific progestin ther- relief from endometriosis-related pain has been option that inhibit ovulation and induce decidu- apies and wishes to have long-term therapy 30 confirmed in several randomized control trials. alization and atrophy of endometriotic lesions.28 (e.g., 5 years or longer), potential long-term Either cyclic or continuous administration of Several progestins are available in Canada, in a impacts on bone and lipid metabolism should combined oral contraceptive pills is accept- variety of formulations, including oral, paren- be discussed. Another clinically useful but less able. However, continuous regimens may be teral, and intrauterine systems; most are used studied progestin is the norethindrone-only 31 more beneficial in reducing pain symptoms. off-label for treatment of endometriosis symp- contraceptive pill (mini-pill), which can be Advantages of prescribing a combined hor- toms [Table 1]. titrated up to obtain amenorrhea. Medroxy- monal contraceptive include relative afford- Dienogest is the only progestin currently progesterone acetate can be prescribed as an ability, ease of use, contraceptive benefits, and approved in Canada for the indication of endo- oral agent or an intramuscular injection (e.g., noncontraceptive benefits such as a reduced risk metriosis treatment. Norethindrone acetate is Depo-Provera). The Depo-Provera form has 32 of endometrial and ovarian cancer. Combined another available effective progestin, with early been associated with a reversible decrease in hormonal contraceptives can be taken safely for studies showing its efficacy in relieving chronic bone mineral density.35

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The levonorgestrel intrauterine system for endometriosis, they should be considered of endometriosis. Based on the available evi- (levonorgestrel-IUD) releases levonorgestrel second-line because they are an expensive and dence and in keeping with national guidelines, locally in the pelvis, thereby reducing the complex form of therapy.37 combined hormonal contraceptives, preferably risk of systemic side effects.21 Because the used continuously, and/or progestin-only thera- levonorgestrel-IUD does not provoke hypo­ GnRH antagonists pies should be considered as first-line options estrogenism and is applied once every 5 years, In contrast to the other medical therapies, and may be started as empirical therapy by the it has been suggested as a favorable treatment GnRH antagonists have only recently become family physician. They may also be combined for women not planning to conceive.36 How- available, with the oral GnRH antagonist elago- with NSAIDs. If there is no improvement in ever, because the levonorgestrel-IUD does not lix approved by Health Canada in 2018. Oral symptoms and no signs of advanced endome- typically suppress ovulation, it is not helpful GnRH antagonists produce a dose-dependent triosis after a 3-month trial, a referral to a com- in treating ovulation pain.36 Furthermore, the hypoestrogenic environment via pituitary go- munity gynecologist is appropriate. In women levonorgestrel-IUD carries a risk of expulsion, nadotropin suppression, which inhibits endo- with suspected endometriosis who are actively pelvic infection, and perforation.21 metriotic cell proliferation.28 The efficacy and pursuing a pregnancy or have impaired fertility, The following second-line therapies are usu- safety of elagolix for the treatment of pain as- referring to a fertility clinic is recommended.27 ally initiated by a gynecologist, but ongoing sociated with endometriosis were established The BC Women’s Centre for Pelvic Pain administration may be provided by the family in two 6-month, phase 3 clinical studies.26 Two and Endometriosis is an interdisciplinary physician. different doses, 150 mg once daily or 200 mg tertiary care centre founded in 2011 to treat twice daily, were compared against placebo. those patients with the most challenging cas- GnRH agonists with add-back therapy Both doses of elagolix significantly improved es of pelvic pain and endometriosis [Table 2]. Several GnRH agonists are available in Can- dysmenorrhea and nonmenstrual pelvic pain The centre has gynecologists with expertise ada and can be administered via intramuscu- during a 6-month period. Both doses resulted in endometriosis surgery and pelvic pain who lar, subcutaneous, or intranasal routes. GnRH in hypoestrogenic effects, including hot flushes collaborate with in-house physiotherapy, coun- agonists suppress gonadotropin secretion and reduced bone mineral density, and the dif- seling, and nursing to provide interdisciplinary (follicle-stimulating hormone and luteinizing ferences were significant when compared with care.39 The centre’s website provides addi- hormone), which stops estrogen production placebo. However, the difference between the tional information for patients and providers by the ovaries. Subsequent hypoestrogenism lower dose of elagolix and placebo was smaller (www.bcwomens.ca/our-services/gynecology/ leads to amenorrhea and hypo-atrophic regres- than that for the higher dose. The potential pelvic-pain-endometriosis). sion of the endometrium.37 GnRH agonists for balancing effectiveness and tolerability by cannot be safely administered for longer than individually titrating the dosage of elagolix, as Summary 6 months due to symptoms of estrogen defi- well as its oral route of administration, are po- There is consistent evidence that endometri- ciency, including a possible irreversible loss of tential advantages of this medication. Add-back osis, particularly endometriosis-related pain, bone mineral density. The concurrent use of therapy may also be used to counter the hy- can have a significant detrimental impact on a add-back hormone therapy, such as low-dose poestrogenic effects. woman’s quality of life. Because women with continuous estrogen with progestin, has enabled endometriosis may suffer physically, socially, extended therapy with maintenance of bone When to refer and emotionally, there is a considerable need for mineral density.38 While GnRH agonists with Pelvic pain management should not be de- earlier diagnosis and treatment. We are shifting add-back therapy are an effective treatment layed in order to obtain surgical confirmation toward a clinical diagnosis of endometriosis and initiation of empiric medical treatment without the need for laparoscopy. A patient Table 2. Criteria for referring to the Centre for Pelvic Pain and Endometriosis. who presents with dysmenorrhea, chronic pelvic pain, or dyspareunia should raise suspicion for a Inclusion criteria Exclusion criteria diagnosis of endometriosis, particularly if they • Advanced endometriosis (ovarian • Age < 16 or > 55 years have other associated symptoms, such as cycli- endometrioma, deep endometriosis, extra-pelvic • Postmenopausal endometriosis) diagnosed either with imaging or cal intestinal or urinary complaints, fatigue, or surgically • Currently pregnant or postpartum < 6 months infertility. It is essential that these symptoms AND/OR • Vestibulitis/vulvodynia/introital dyspareunia only are not normalized or dismissed. Dysmenor- • Persistent pelvic pain that is unresponsive to • Myofascial/back pain only rhea that interferes with a woman’s ability to first-line management (treated by a gynecologist • Neuropathic pain only function in her daily life and is not responsive within the last 3 years) • Unstable or untreated psychiatric issues to over-the-counter medication needs to be • Untreated or ongoing substance abuse taken seriously. A recent systematic review of the effects of endometriosis on women’s lives

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and possible consequences. Hum Reprod 2012;27: 23. Fraser MA, Agarwal S, Chen I, Singh SS. Routine vs. ex- reported that even if primary care physicians 3412-3416. pert-guided transvaginal ultrasound in the diagnosis lacked in-depth knowledge of endometriosis, 10. Ballard K, Lowton K, Wright J. What’s the delay? A quali- of endometriosis: A retrospective review. Abdom Im- women were satisfied if they felt heard, were tative study of women’s experiences of reaching a diag- aging 2015;40:587-594. treated with sympathy, and were referred ap- nosis of endometriosis. Fertil Steril 2006;86:1296-1301. 24. Tavcar J, Loring M, Movilla PR, Clark NV. Diagnosing propriately.11 It is important to inquire about 11. Young K, Fisher J, Kirkman M. Women’s experiences of endometriosis before laparoscopy: Radiologic tools endometriosis: A systematic review and synthesis of to evaluate the disease. Curr Opin Obstet Gynecol areas of life known to be adversely affected by qualitative research. J Fam Plann Reprod Health Care 2020;32:292-297. endometriosis to better provide patient-centred 2015;41:225-234. 25. Jacobson TZ, Duffy JMN, Barlow D, et al. Laparoscopic treatment, including adaptive coping strategies, surgery for pelvic pain associated with endometriosis. stress reduction, emotional and social support, Cochrane Database Syst Rev 2009;7:CD001300. We are shifting toward 26. Taylor HS, Giudice LC, Lessey BA, et al. Treatment of and career counseling. Ultimately, primary care endometriosis-associated pain with Elagolix, an oral physicians should feel empowered to clinically a clinical diagnosis GnRH antagonist. N Engl J Med 2017;377:28-40. diagnose endometriosis. Recognizing endome- of endometriosis and 27. Brown J, Farquhar C. Endometriosis: An overview of triosis and initiating empiric treatment earlier Cochrane Reviews. Cochrane Database Syst Rev 2014; initiation of empiric 2014:CD009590. is a critical step to improving not only the care medical treatment 28. Bedaiwy MA, Allaire C, Yong P, Alfaraj S. Medical man- but also the quality of life of the patients who agement of endometriosis in patients with chronic suffer from this disease.n without the need pelvic pain. Semin Reprod Med 2017;35:38-53. for laparoscopy. 29. Brown J, Crawford TJ, Allen C, et al. Nonsteroidal anti- Competing interests inflammatory drugs for pain in women with endome- Dr Allaire has participated in a clinical trial within triosis. Cochrane Database Syst Rev 2017;1:CD004753. 30. Harada T, Kosaka S, Elliesen J, et al. Ethinylestradiol 20 the last 2 years, is a member of an advisory board 12. Denny E, Mann CH. Endometriosis and the primary μg/drospirenone 3 mg in a flexible extended regi- with the commercial organization Abbvie, and care consultation. Eur J Obstet Gynecol Reprod Biol men for the management of endometriosis-associated has received an honorarium from the commercial 2008;139:111-115. pelvic pain: A randomized controlled trial. Fertil Steril organization Hologic. Dr Dunne is a member of 13. Rowe HJ, Hammarberg K, Dwyer S, et al. Improving 2017;108:798-805. clinical care for women with endometriosis: Quali- 31. Muzii L, Di Tucci C, Achilli C, et al. Continuous versus the BCMJ Editorial Board but did not participate tative analysis of women’s and health profession- cyclic oral contraceptives after laparoscopic excision in the decision making regarding the review and als’ views. J Psychosom Obstet Gynecol 2019. doi: of ovarian endometriomas: A systematic review and acceptance of this article for publication. 10.1080/0167482X.2019.1678022. metaanalysis. Am J Obstet Gynecol 2016;214:203-211. 14. Agarwal SK, Chapron C, Giudice LC, et al. Clinical diag- 32. Black A, Guilbert E, Costescu D, et al. No. 329-Cana- nosis of endometriosis: A call to action. Am J Obstet dian Contraception Consensus Part 4 of 4 Chapter 9: References Gynecol 2019;220:354,e1-354.e12. Combined hormonal contraception. J Obstet Gynae- 1. Giudice LC. Endometriosis. N Engl J Med 2010; 15. Brawn J, Morotti M, Zondervan KT, et al. Central changes col Can 2017;39:229-268. 362:2389-2398. associated with chronic pelvic pain and endometrio- 33. Godfrey EM, Whiteman MK, Curtis KM. Treatment of 2. Kuznetsov L, Dworzynski K, Davies M, Overton C. Di- sis. Hum Reprod Update 2014;20:737-747. unscheduled bleeding in women using extended- or agnosis and management of endometriosis: Summary 16. Sourial S, Tempest N, Hapangama DK. Theories on continuous-use combined hormonal contraception: of NICE guidance. BMJ 2017;358:j3935. the pathogenesis of endometriosis. Int J Reprod Med A systematic review. Contraception 2013;87:567-575. 3. Ling CM, Lefebvre G. Extrapelvic endometriosis: A case 2014;2014:179515. 34. Muneyyirci-Delale O, Karacan M. Effect of norethin- report and review of the literature. J Soc Obstet Gyn- 17. Seli E, Berkkanoglu M, Arici A. Pathogenesis of endo- drone acetate in the treatment of symptomatic en- aecol Can 2000;22:97-100. metriosis. Obstet Gynecol Clin North Am 2003;30:41-61. dometriosis. Int J Fertil Womens Med 1998;43:24-27. 4. Vercellini P, Fedele L, Aimi G, et al. Association between 18. Williams C, Long AJ, Noga H, et al. East and South East 35. Black A, Guilbert E, Costescu D, et al. Canadian Contra- endometriosis stage, lesion type, patient character- Asian ethnicity and moderate-to-severe endometrio- ception Consensus (Part 3 of 4): Chapter 8 – Proges- istics and severity of pelvic pain symptoms: A mul- sis. J Minim Invasive Gynecol 2019;26:507-515. tin-only contraception. J Obstet Gynaecol Can 2016; tivariate analysis of over 1000 patients. Hum Reprod 19. Veasley C, Clare D, Clauw D, et al. Impact of chronic 38:279-300. 2007;22:266-271. overlapping pain conditions on public health and 36. Petta CA, Ferriani RA, Abrao MS, et al. Randomized 5. Dunselman GAJ, Vermeulen N, Becker C, et al. ESHRE the urgent need for safe and effective treatment: 2015 clinical trial of a levonorgestrel-releasing intrauterine guideline: Management of women with endometrio- analysis and policy recommendations. Milwaukee, WI: system and a depot GnRH analogue for the treatment sis. Hum Reprod 2014;29:400-412. Chronic Pain Research Alliance; 2015. Accessed 22 Sep- of chronic pelvic pain in women with endometriosis. 6. Ballard KD, Seaman HE, De Vries CS, Wright JT. Can tember 2020. www.chronicpainresearch.org/public/ Hum Reprod 2005;20:1993-1998. symptomatology help in the diagnosis of endome- CPRA_WhitePaper_2015-FINAL-Digital.pdf. 37. Brown J, Pan A, Hart RJ. Gonadotrophin-releasing hor- triosis? Findings from a national case-control study– 20. Taylor HS, Adamson GD, Diamond MP, et al. An evi- mone analogues for pain associated with endometrio- Part 1. BJOG 2008;115:1382-1391. dence-based approach to assessing surgical versus sis. Cochrane Database Syst Rev 2010;2010:CD008475. 7. Culley L, Law C, Hudson N, et al. The social and psy- clinical diagnosis of symptomatic endometriosis. Int 38. Bedaiwy MA, Casper RF. Treatment with leuprolide chological impact of endometriosis on women’s J Gynaecol Obstet 2018;142:131-142. acetate and hormonal add-back for up to 10 years in lives: A critical narrative review. Hum Repro Update 21. Leyland N, Casper R, Laberge P, et al. Endometriosis: stage IV endometriosis patients with chronic pelvic 2013;19:625-639. Diagnosis and management. J Obstet Gynaecol Can pain. Fertil Steril 2006;86:220-222. 8. Levy AR, Osenenko KM, Lozano-Ortega G, et al. Eco- 2010;32:S1-S32. 39. Allaire C, Williams C, Bodmer-Roy S, et al. Chronic pelvic nomic burden of surgically confirmed endometriosis 22. Nisenblat V, Bossuyt PM, Farquhar C, et al. Imaging mo- pain in an interdisciplinary setting: 1-year prospective in Canada. J Obstet Gynaecol Can 2011;33:830-837. dalities for the non-invasive diagnosis of endometrio- cohort. Am J Obstet Gynecol 2018;281:114.e1-114.e12. 9. Hudelist G, Fritzer N, Thomas A, et al. Diagnostic de- sis. Cochrane Database Syst Rev 2016;2:CD009591. lay for endometriosis in Austria and Germany: Causes

BC Medical Journal vol. 63 no. 4 | May 2021 163 Clinical

Samantha Pawer, BSc, Fahra Rajabali, MSc, Jennifer Smith, BFA, Alex Zheng, MSc, Anand Dhatt, Roy Purssell, MD, FRCPC, Ian Pike, PhD Self-poisoning among British Columbian children and youth: Demographic and geographic characteristics

A study on the alarmingly high rates and increasing trends of self-poisoning among children and youth in BC found that 10- to 19-year-olds living in rural neighborhoods with poor access to local mental health services are at highest risk.

ABSTRACT Results: There were 20 413 self-poisoning hospi- Newfoundland and Labrador, self-poisoning Background: Poisoning is a common self-harm talizations (55.8 per 100 000 population) in BC, hospitalizations among 12- to 17-year-olds method, but the magnitude of the problem in Brit- including 3842 among 10- to 19-year-olds (92.9 per increased 2.7-fold.3 Meanwhile, previous re- ish Columbia is unclear. This study aimed to review 100 000 population). Rates significantly increased search by our group indicated that in British self-poisoning hospitalization trends in BC, with a 2.7-fold for 10- to 14-year-olds (24.0 to 64.7 per Columbia, 15- to 19-year-old females had focus on 10- to 19-year-olds. 100 000 population) and 1.7-fold for 15- to 19-year- the highest self-poisoning hospitalization rate olds (103.9 to 180.1 per 100 000 population) over Methods: Self-poisoning hospitalization rates were (191.6 per 100 000 population) compared to the study period. Rates were highest in rural areas all other age groups.4 These findings are highly calculated by age group, sex, and year for the fis- with poorly distributed mental health services, cal periods 2009–10 to 2016–17. Among 10- to concerning because self-poisoning is associated relative to urban regions. with greater risks of suicide and accidental 19-year-olds, rates by census division for the fis- 5 cal periods 2012–13 to 2016–17 were calculated Conclusions: These findings highlight the need to death. and compared to the availability of local mental tailor prevention strategies for youth and increase With increasing trends in self-poisoning health services. access to mental health services throughout BC. and the significant cost of treating such inju- ries, the Canadian health care system is facing a growing burden. Per patient, self-poisoning Background Ms Pawer is a research assistant, Ms Rajabali hospitalizations are more expensive than Self-poisoning is a major public health con- is a researcher, Ms Smith is a research other self-inflicted injuries such as cutting, cern in Canada, particularly among children coordinator, Mr Zheng is a biostatistician, hanging, and jumping.6 Annually, suicide and and youth. Among 10- to 17-year-old Canadi- and Mr Dhatt is an undergraduate student self-harm costs in Canada exceed $76 mil- ans, 2140 young people were hospitalized due at the BC Injury Research and Prevention lion for 10- to 14-year-olds and $426 mil- to self-poisoning during the 2013–14 fiscal Unit. Dr Purssell is a professor in the lion for 15- to 19-year-olds.7,8 The per capita year, which accounted for 87% of hospitaliza- Department of Emergency Medicine, 1 cost of suicide and self-harm in BC is higher tions due to self-inflicted injuries. Parachute University of British Columbia, and medical for youth than for adults,6,9 at $216 among and Alberta’s Injury Prevention Centre found lead of the BC Drug and Poison Information 15- to 24-year-olds and $137 among 25- to that between the 2008–09 and 2018–19 fis- Centre. Dr Pike is director of the BC Injury 64-year-olds.8,9 cal periods, 10- to 14-year-old and 15- to Research and Prevention Unit and is a Child and youth self-poisoning is highly 19-year-old Canadians had the largest percent professor in the Department of Pediatrics, taxing economically and socially, which makes increases in self-poisoning hospitalizations, University of British Columbia. it of utmost importance that action be taken to with an average yearly increase of 12.6% and 2 reduce occurrences of these preventable injuries. This article has been peer reviewed. 6.9%, respectively. Between 2008 and 2013 in

164 BC Medical Journal vol. 63 no. 4 | May 2021 Pawer S, Rajabali F, Smith J, Zheng A, Dhatt A, Purssell R, Pike I Clinical

Reasons for the increase in self-poisoning preventive, diagnostic, and multidisciplinary Rates of self-poisoning hospitalizations per among children and youth are unknown, al- programs, as well as a map of the province di- 100 000 population of children and youth were though a mental health diagnosis is a factor.3 In vided by CD, were acquired from the BC Data calculated for each CD. These rates were dis- 2003, the BC Ministry of Children and Family Catalogue.14 BC population data by DA were played as a heat map of BC using the Quan- Development introduced the Child and Youth collected from Statistics Canada’s 2011 and tum Geographic Information System software Mental Health Plan10 to provide free mental 2016 Census Profiles.15 (QGIS; version 3.6.2-Noosa). The density of health services for children and young people youth mental health services was calculated for up to 18 years old in BC, although a 2019 BC each CD by adding the number of services per Coroners Service report recommended that Among all British CD, divided by the 10- to 19-year-old popula- youth mental health services be expanded in Columbians, 15- to tion of that CD, and multiplying by 100. These 11 nonurban areas. While these services are 19-year-olds had values were overlaid on the heat map. Using imperative to support the positive well-being QGIS, the distribution of clusters of youth of young British Columbians, it is unknown the highest rate of mental health services was also included on whether proximity to them reduces local rates self-poisoning, with the map. of child and youth self-harm. significantly greater To explore gaps in existing literature and rates for females Results to inform youth self-harm prevention strate- Between 1 April 2009 and 31 March 2017, compared to males. gies, our study had two goals. The first was to there were 20 413 (55.8 per 100 000 population) explore detailed epidemiological self-poisoning self-poisoning hospitalizations in BC, 3842 of hospitalization trends in BC; the second was which were among 10- to 19-year-olds (92.9 to describe rates among 10- to 19-year-olds by Descriptive statistics and Wald’s 95% confi- per 100 000 population). Six self-poisonings geographic region in relation to accessibility of dence intervals were calculated. Hospitalization (0.03% of cases) were excluded due to a miss- local mental health resources. rates per 100 000 population were calculated by ing sex identifier. age group, using the total number of poison- Among all British Columbians, 15- to 19- Methods ing events over the study period divided by year-olds had the highest self-poisoning rate; Self-poisoning hospitalization data in BC the respective age group population and then the rate among 10- to 14-year-olds was rela- from the 2009–10 to 2016–17 fiscal years were multiplied by 100 000. Poisoning rates among tively moderate. For both children and youth, retrospectively described in terms of epide- 10- to 14-year-olds and 15- to 19-year-olds rates were significantly greater for females com- miological trends and patterns. This study was were compared with other age groups by year pared to male age-mates [Figure 1]. approved by the University of British Colum- of occurrence and sex. Results were considered During the 2009–10 to 2016–17 fiscal pe- bia/Children’s and Women’s Health Centre significant if the 95% confidence intervals did riods, 10- to 14-year-olds and 15- to 19-year- of British Columbia Research Ethics Board not overlap. olds demonstrated the greatest increases in (#H13-01321). From 1 April 2009 to 31 March 2017, hos- pitalization data for all ages were obtained from 250 the Discharge Abstract Database, BC Ministry Males of Health. From 1 April 2012 to 31 March 200 Females 2017, hospitalizations were extracted from the Overall database by dissemination area (DA: a geo- 150 graphic area with approximately 400 to 700 residents12) for 10- to 19-year-olds, and were 100

converted to census divisions (CD: a group Rate (per 100 000) of neighboring municipalities comprised of 50 numerous DAs12). Data were extracted using the most responsible diagnosis codes for intent (X60 to X69), as well as poisoning (T36 to 0 10–14 15–19 20–24 25–44 45–64 65–74 75+ T65), as per the International Statistical Clas- Age group (years) sification of Diseases and Related Health Prob- lems, Canadian version 10 (ICD-10-CA).13 Figure 1. Self-poisoning hospitalization rates per 100 000 population in BC, 2009–10 to 2016–17 fiscal years, The geocode location of all public youth mental 75+ by age group200 and sex, with 95% confidence intervals. Note: 0- to 9-year-olds were excluded because there health services in BC, including interventional, 65–74 were fewer than 5 cases.45– 64 25–44 160 20–24 BC Medical Journal vol. 63 no. 4 | May 2021 165 15–19 10–14 120

80 Rate (per 100 000) 40

0 2009–10 2010–11 2011–12 2012–13 2013–14 2014–15 2015–16 2016–17

Fiscal year

350 15- to 19-year-old males 300 15- to 19-year-old females 10- to 14-year-old males 250 10- to 14-year-old females

200

150

Rate (per 100 000) 100

50

0 2009–10 2010–11 2011–12 2012–13 2013–14 2014–15 2015–16 2016–17

Fiscal year Clinical Self-poisoning among British Columbian children and youth self-poisoning hospitalization rates compared males, and 3.0-fold from 40.6 (29.3–52.0) to population), Central Coast (337.4 per 100 000 with all250 other age groups [Figure 2A]. Rates 121.9 (101.5–142.3) per 100 000 population population), and Northern Rockies (328.4 per increased 2.7-foldMales from 24.0 (17.9–30.0) for 10- to 14-year-old females. Among 15- to 100 000 population) [Figure 3]. Those with to 64.7200 (54.3–75.0) Females per 100 000 population 19-year-olds, rates increased 1.5-fold from 46.2 the lowest rates were Stikine (0 cases), Mount among 10- to 14-year-olds,Overall and 1.7-fold from (35.1–57.3) to 69.8 (56.0–83.6) per 100 000 Waddington (< 5 cases), and Kootenay Bound- 103.9 (91.9–115.8) to 180.1 (164.2–196.0) per population for males, and 1.8-fold from 166.2 ary (39.7 per 100 000 population). 150 100 000 population among 15- to 19-year- (144.4–188.0) to 297.2 (267.9–326.6) per In terms of mental health service density for olds. Among children and youth, increas- 100 000 population for females. children and youth, Stikine, Mount Wadding- es were100 largely among females [Figure 2B]. Between 1 April 2012 and 31 March 2017, ton, and Kitimat-Stikine had the most services, Rate (per 100 000) Self-poisoning hospitalization rates increased of the 29 CDs in BC, those with the high- with 20.0, 2.9, and 2.5 per 100 population of 1.3-fold 50from 8.5 (3.5–13.5) to 10.9 (5.0–16.8) est child and youth self-poisoning rates were 10- to 19-year-olds, respectively, while Capi- per 100 000 population for 10- to 14-year-old Skeena-Queen Charlotte (422.9 per 100 000 tol, Fraser Valley, and Central Okanagan had 0 the fewest services, with 0.6 per 100 popula- 10–14 15–19 20–24 25–44 45–64 65–74 75+ tion of 10- to 19-year-olds. Census divisions Age group (years) with the high rates of self-poisoning, such as A Skeena-Queen Charlotte, Central Coast, and Northern Rockies, had small clusters of mental 200 75+ 65–74 health services, with poor coverage in many 45–64 rural areas [Figure 3]. 25–44 160 20–24 15–19 Conclusions 10–14 Self-poisoning is a considerable issue in BC, 120 where high rates and increasing trends among children and youth are alarming. In surveys 80 administered to a large representative sample of young people age 14 to 21 in Victoria, BC, Rate (per 100 000) in 2003 and 2005, 17% of participants admit- 40 ted to performing at least one act of nonsui- cidal self-harm.16 More recently, our study 0 has highlighted that self-poisoning is a sig- 2009–10 2010–11 2011–12 2012–13 2013–14 2014–15 2015–16 2016–17 nificant and growing problem, particularly Fiscal year for BC children and youth. The exceptionally B high self-poisoning rates among females age 350 10 to 14 and 15 to 19 are striking, which is 15- to 19-year-old males consistent with research that has found higher 300 15- to 19-year-old females self-poisoning rates among female youth com- 10- to 14-year-old males pared with males.3 Although self-poisoning 250 10- to 14-year-old females is more severe among young females, in the

200 2016–17 fiscal year, self-poisoning hospital- ization rates among males age 15 to 19 in BC 150 surpassed those of all other male age groups. The growing number of 10- to 19-year-old

Rate (per 100 000) 100 self-poisonings in BC is of great concern. The factors driving these increases are mostly specu- 50 lative, although depression—a demonstrated

0 risk factor for adolescent self-poisoning in 3 2009–10 2010–11 2011–12 2012–13 2013–14 2014–15 2015–16 2016–17 Newfoundland and Labrador —could also be central to the issue in BC. There is an absence Fiscal year of literature regarding the impact of geography of residence and availability of local mental Figure 2. Self-poisoning hospitalization rates per 100 000 population in BC, 2009–10 to 2016–17 fiscal years, for (A) all age groups, and (B) children and youth by sex. health services on self-poisoning rates among

166 BC Medical Journal vol. 63 no. 4 | May 2021 Pawer S, Rajabali F, Smith J, Zheng A, Dhatt A, Purssell R, Pike I Clinical

Lower Mainland and Southern Vancouver Island inset

Rates per 100 000 population

0 158 422

Service No. of Poisoning Poisoning Service No. of Poisoning Poisoning Census division Census division density services rate 95% CI density services rate 95% CI

Fraser Valley 0.61 218 131.16 93.69-168.63 Alberni-Clayoquot 1.62 51 248.01 74.17-421.85

Kitimat-Stikine 2.51 115 209.38 77.07-341.69 Strathcona 1.15 53 104.46 11.06-197.86

Squamish-Lillooet 1.56 65 72.12 0-153.7 Cowichan Valley 1.12 98 217.77 119.96-315.58

Cariboo 1.54 102 166.04 68.00-264.08 Comox Valley 0.77 50 128.54 41.67-215.41

Powell River 0.93 17 76.50 0-200.18 Nanaimo 0.76 108 111.27 56.44-166.1

Greater Vancouver 0.44 1164 71.54 61.36-81.72 Capital 0.62 221 142.18 103.11-181.25

Sunshine Coast 1.34 33 72.87 0-179.29 Central Kootenay 2.47 147 87.54 12.33-162.75

Central Coast 0.72 3 337.35 0-895.23 Kootenay Boundary 2.02 61 39.74 0-110.82

Stikine 20.00 8 0 0 Columbia-Shuswap 1.67 80 183.91 62.51-305.31

Skeena-Queen Charlotte 2.47 56 422.91 155.95-689.87 East Kootenay 1.52 95 121.31 35.12-207.50

Northern Rockies 1.79 12 328.36 0-761.55 Thompson-Nicola 1.39 194 178.29 108.18-248.40

Bulkley-Nechako 1.77 88 201.41 76.70-326.12 Okanagan-Similkameen 1.35 99 250.17 136.00-364.34

Peace River 1.10 88 142.5 103.43-181.57 North Okanagan 1.11 96 210.16 113.71-306.61

Fraser-Fort George 0.97 108 123.55 58.41-188.69 Central Okanagan 0.55 109 163 107.09-218.91

Mount Waddington 2.92 37 * *

Figure 3. BC heat map of child and youth self-poisoning rates per 100 000 population by census division for 10- to 19-year-olds, 2012–13 to 2016–17 fiscal years, overlaid by youth mental health services per 100 population of 10- to 19-year-olds (service density) and service clusters. Numbers in green circles represent the number of local services. Asterisks represent more than 0 but fewer than 5 cases.

BC Medical Journal vol. 63 no. 4 | May 2021 167 Clinical Self-poisoning among British Columbian children and youth

BC children and youth. Our findings have ad- An additional screening opportunity ex- who discussed the experiences they had as 16- dressed these gaps by demonstrating that young ists within emergency departments. With to 18-year-olds involved with mental health people age 10 to 19 living in rural neighbor- development led at BC Children’s Hospital, services (15-year-olds shared their expecta- hoods with poor access to local mental health the HEARTSMAP mental health assess- tions).26 Main talking points also included the services are at higher risk for self-poisoning ment tool is used throughout much of BC lack of services in rural BC, as well as fears that than those living elsewhere. by emergency department clinicians to screen relocating in order to access services leads to Given the recent increases in depression children and youth who present with men- isolation from support systems, and thus causes diagnoses and antidepressant prescriptions for tal health emergencies.24 An adapted version more harm than benefit. Those who moved females age 12 to 19,17 mental health and anti- back to their rural communities after receiv- depressant accessibility may have contributed ing mental health care in urban centres often to increased self-poisoning rates among female Existing self-harm mentioned that services and follow-up care youths. Mental health and the use of antide- prevention methods were not available locally. Our study found that pressants, however, are complicated subjects include gatekeeper many census divisions with the greatest density in relation to self-harm and suicide. Although training, screening for of youth mental health services had the lowest Health Canada has not approved the use of any self-poisoning rates, which suggests that greater high-risk individuals, antidepressants by minors, and antidepressants availability of mental health services may be increase young people’s risk of suicide ideation, encouraging help- associated with improved mental health and, the benefits of antidepressant treatment greatly seeking behavior, therefore, fewer acts of self-harm. 18 outweigh the potential dangers. For physi- and providing access To improve health care in high-risk re- cians who prescribe off-label antidepressants to crisis lines and gions, the Ontario Hospital Association to children and youth, close monitoring is es- launched Local Health Hubs for Rural and sential. The most common reason for adolescent online resources. Northern Communities,27 which provide com- self-harm is the desire to relieve psychological prehensive health care in one rural location. pain.19 With patients at high risk for self-harm, Mental health services are incorporated into physicians can discuss healthier methods of ex- called myHEARTSMAP, a self-assessment this model, with the aim to improve screen- pressing emotions, such as exercising, listening tool that was validated among young people ing and treatment.28 Local Health Hubs liaise to music, or calling a friend.20 age 10 to 17 in Western Canada, was used with larger health care centres to facilitate Existing self-harm prevention methods to pronounce psychosocial challenges among referrals and telemedicine for patients, and include gatekeeper training, screening for emergency department patients with nonmen- provide mental health education and support high-risk individuals, encouraging help-seeking tal health presentations and provide treatment for rural physicians.28 Having Local Health behavior, and providing access to crisis lines recommendations when needed.24 Upon com- Hubs in northern and rural BC may improve and online resources.21 Evidence supports the paring myHEARTSMAP results to those from mental health services for children and youth importance of self-harm screening and risk HEARTSMAP assessments conducted by residing in those locations, although the ef- assessment.22 For this to be effective, the BC research nurses, 92.7% of youth were able to ficacy of this system has not yet been proven Ministry of Children and Family Development identify their own psychiatric issues. Of all due to its novelty in Canada.28 recommends that family physicians regularly participating patients, 36.4% were determined The BC Child and Youth Mental Health repeat training for the recognition and treat- to have psychosocial concerns, which is higher Plan states that all children, from birth to 18 ment of depression.23 than what has been observed across Canada.24 years old, should have access to basic mental To help address this issue in BC, not only Accordingly, employing myHEARTSMAP health services,10 but there are inconsistencies should physicians familiarize themselves with the in BC emergency departments is expected to in the services provided to children and youth signs associated with high risk of self-harm, but improve detection of mental health concerns in different regions of the province. Further- they can also discuss depression and anxiety with among high-risk children and youth, and pro- more, by mapping the distribution of youth their child and youth patients, and refer those vide customized care plans to potentially reduce mental health services, we found that services patients to pediatricians, psychiatrists, or local rates of self-harm among young people age 10 are scarce in several areas. For example, in the mental health services if necessary. Although im- to 19 throughout the province. Northern Rockies, all 12 youth mental health proved mental health screening and treatment in In focus groups held in 2010 and 2015 for services are located in Fort Nelson,14 which BC may reduce self-poisoning incidents among 12- to 22-year-olds in rural and urban BC, has an area of 13 km2 and a 10- to 19-year-old children and youth, not all 10- to 19-year-olds a key suggestion for improving youth health population of 400 individuals.15 The rest of who poison themselves are mentally ill, and many was to increase accessibility to mental health the census division has an area of 85 098 km2 will not take the initiative to address their con- counselors.25 In 2013, focus groups were held and a 10- to 19-year-old population of 270 cerns with a health care practitioner. with youth age 15 to 25 in rural and urban BC, individuals,15 meaning that many children and

168 BC Medical Journal vol. 63 no. 4 | May 2021 Pawer S, Rajabali F, Smith J, Zheng A, Dhatt A, Purssell R, Pike I Clinical youth living in northeastern BC (where there Data limitations Finally, due to coding limitations of the hos- is no public transit) have to drive for hours to Since there were no personal identifiers in the pitalization data, this study could not differenti- access mental health services. Often, this is available data, hospital readmissions and trans- ate between suicide attempts and nonsuicidal simply not feasible. Of all 29 census divisions, fers could not be excluded. We estimate that self-injury, but rather grouped these behaviors the Northern Rockies had the third highest approximately 4% of self-poisoning hospital- as self-poisonings. rate of self-poisoning hospitalizations among izations were either readmissions or transfers, children and youth age 10 to 19. meaning that the number of double-counted Summary The situation was similar for the Central individuals represents a small proportion of Self-poisoning is an ongoing issue for children Coast census division, which had the second age 10 to 14 and youth age 15 to 19. From highest rate of self-poisoning among 10- to 1 April 2009 to 31 March 2017, the children 19-year-olds, yet just three youth mental health The study highlights and youth in this age range in BC demonstrated services. Due to the rugged landscape of the the need for high rates of self-poisoning hospitalizations, Central Coast, modes of travel are costly and which unlike any other age group, increased time-consuming, which makes it nearly im- implementation of, throughout the study period. It is important possible for many children and youth to ob- and improved access to, to assess potential risk factors that are con- tain in-person mental health treatment. This additional youth tributing to the increased self-poisoning rates emphasizes the need for implementation of, services in rural and among children and youth, and to explore rea- and improved access to, additional services in sons for higher rates among females age 10 to isolated areas of BC. rural and isolated areas of BC. While under- 19 compared with males, including the role of used across Canada during the study period,29 mental health. Children and youth age 10 to telehealth provides a potential solution. More 19 living in rural neighborhoods that have low recently, the COVID-19 pandemic has resulted accessibility to mental health services are the in a shift to telehealth use, which removes many the total number of cases. On the other hand, most vulnerable to self-poisoning. This reveals barriers to accessing health care; for example, the data are not all encompassing, in that they an urgent public health issue in BC—one that by eliminating the need to travel to urban cen- include only cases for which poisoning was the medical practitioners can act on by advocating tres. However, limitations still exist, including primary cause, not those for which poisoning for more and/or greater access to youth men- insufficient bandwidth and inadequate access was a contributing factor. Therefore, this study tal health services in high-risk regions. In the to technology. Key locations of focus identified likely underrepresented the total number of meantime, physicians should monitor young in this study include rural areas in the Northern self-poisoning hospitalizations in BC. patients for signs of mental health concerns, Rockies, Central Coast, Skeena-Queen Char- Factors that vary across geographic regions, and closely follow up with those who have been lotte, Kitimat-Stikine, and Bulkley-Nechako, such as economic conditions, the nature of jobs, prescribed antidepressants. With patients who which were census divisions with high rates types and availability of social supports, eth- might be at high risk of self-harm, physicians of self-poisoning among children and youth nic composition, and culture, could not be ac- can also discuss alternative coping strategies age 10 to 19. counted for in this study. It is challenging to to help reduce the number of self-harm cases Child and youth self-poisoning needs to be compare youth mental health services availabil- among young British Columbians. Still, fu- urgently addressed. Our study identified critical ity among census divisions because the char- ture research should be conducted to explore rural areas in BC that would benefit from more acteristics of each varies greatly with another. the efficacy of existing self-harm prevention accessible youth mental health services, and For example, Stikine had a small population of strategies and youth mental health services in highlighted the need for self-harm prevention only 40 children and youth age 10 to 19, which high-risk areas. n strategies in those areas. Ultimately, it is ideal could account for the high density of youth to prevent self-harm among children and youth mental health services—nearly tenfold higher Competing interests by employing a layered strategy with multiple than any other census division. If Stikine and None declared. approaches that reduce risk and promote posi- Greater Vancouver were each 10 000 km,2 they tive well-being. A valuable opportunity exists would have 6 and 920 636 residents aged 10 to References 15 1. Canadian Institute for Health Information. Self-harm and for public health officials, policymakers, clini- 19 years, respectively. With these different assault: A closer look at children and youth. Ottawa, ON; cians, and mental health workers to develop population densities, a greater density of youth 2014. Accessed 6 February 2020. https://secure.cihi.ca/ and amend self-harm reduction strategies for mental health services does not equate to easier estore/productFamily.htm?locale=en&pf=PFC2720& children and youth, thereby reducing the burden access, use, or equitable or culturally safe access _ga=2.118724234.2091214653.1581031439-724938484 .1571786949. that these preventable injuries have on Brit- within that region, particularly in remote census 2. Jiang A, Belton K, Fuselli P. Evidence summary on ish Columbians, our economy, and our health divisions that have small populations dispersed the prevention of poisoning in Canada. Toronto, ON: care system. over large geographic areas. Parachute; 2020. Accessed 10 December 2020. https://

BC Medical Journal vol. 63 no. 4 | May 2021 169 Clinical Self-poisoning among British Columbian children and youth

parachute.ca/wp-content/uploads/2020/11/Evidence 13. Canadian Institute for Health Information. Canadian 19. Rasmussen S, Hawton K, Philpott-Morgan S, O’Connor -Summary-on-Poisoning-in-Canada-UA.pdf. coding standards for Version 2018 ICD-10-CA and RC. Why do adolescents self-harm? An investigation of 3. Chafe R, Aslanova R, Hamud O, et al. Hospitalizations CCI. Ottawa, ON; 2018. Accessed 6 February 2020. motives in a community sample. Crisis 2016;37:176-183. due to self-poisoning at a Canadian paediatric hospi- https://secure.cihi.ca/free_products/CodingStandards 20. Nemours Foundation. Teens health: How can I stop cut- tal. Paediatr Child Health 2018;23:101-105. _v2018_EN.pdf. ting? Jacksonville, FL; 2015. Accessed 8 January 2020. 4. Jiang A, Smith J, Rajabali F, et al. Patterns in poisoning 14. Government of BC. BC data catalogue. Victoria, BC; https://kidshealth.org/en/teens/resisting-cutting.html. hospitalizations and deaths in British Columbia, 2008 2019. Accessed 18 December 2019. https://catalogue 21. Hawton K, Saunders KEA, O’Connor RC. Self-harm and to 2013. BCMJ 2018;60:495-502. .data.gov.bc.ca/dataset?download_audience=Public. suicide in adolescents. Lancet 2012;379:2373-2382. 5. Finkelstein Y, Macdonald EM, Hollands S, et al. Long- 22. Rosenbaum Asarnow J, Mehlum L. Practitioner review: term outcomes following self-poisoning in adolescents: Treatment for suicidal and self-harming adolescents— A population-based cohort study. Lancet Psychiatry advances in suicide prevention care. J Child Psychol 2015;2:532-539. Physicians should Psychiatry 2019;60:1046-1054. 6. Tsiachristas A, McDaid D, Casey D, et al. General hos- monitor young patients 23. White J. Preventing youth suicide: A guide for practi- pital costs in England of medical and psychiatric care tioners. Victoria, BC: Ministry of Children and Family for patients who self-harm: A retrospective analysis. for signs of mental Development; 2016. Accessed 23 July 2019. www2.gov Lancet Psychiatry 2017;4:759-767. health concerns, .bc.ca/assets/gov/health/managing-your-health/ 7. Parachute. The cost of injury in Canada. Toronto, ON; mental-health-substance-use/child-teen-mental 2015. Accessed 6 February 2020. https://parachute.ca/ follow up closely with -health/preventing_youth_suicide_practitioners wp-content/uploads/2019/06/Cost_of_Injury-2015.pdf. those prescribed _guide.pdf. 8. Bank of Canada. Inflation calculator. Ottawa, ON; 2020. 24. Doan Q, Wright B, Atwal A, et al. Utility of MyHEARTS- Accessed 30 January 2020. www.bankofcanada.ca/ antidepressants, and MAP for universal psychosocial screening in the emer- rates/related/inflation-calculator. discuss alternative gency department. J Pediatr 2020;219:54-61.e1. 9. Rajabali F, Ibrahimova A, Barnett B, Pike I. Economic 25. Smith A, Peled M. Talking about youth health: An ex- burden of injury in British Columbia. Vancouver, BC: BC coping strategies ample of engaging youth to improve child and youth Injury Research and Prevention Unit; 2015. Accessed 6 with those at high health indicators in British Columbia, Canada. Child In- February 2020. www.injuryresearch.bc.ca/wp-content/ dic Res 2017;10:353-362. uploads/2015/08/BCIRPU-EB-2015-1.pdf. risk of self-harm. 26. Cox K, Smith A, Poon C, et al. Take me by the hand: 10. Berland A. A review of child and youth mental health Youth’s experiences with mental health services in services in BC. Victoria, BC: BC Ministry of Children BC. Vancouver, BC: McCreary Centre Society; 2013. Ac- and Family Development; 2008. Accessed 6 February 15. Statistics Canada. Census profile, 2016 Census. Otta- cessed 5 November 2019. www.mcs.bc.ca/pdf/take 2020. https://cwrp.ca/sites/default/files/publications/ wa, ON; 2016. Accessed 18 December 2019. www12 _me_by_the_hand.pdf. BC-CYMH_Review_report.pdf. .statcan.gc.ca/census-recensement/2016/dp-pd/prof/ 27. Ontario Hospital Association. Local health hubs for 11. BC Coroners Service. Supporting youth and health index.cfm?Lang=E. rural and northern communities: An integrated ser- professionals: A report on youth suicides. Victoria, BC; 16. Nixon M, Cloutier P, Jansson SM. Nonsuicidal self-harm vice delivery model whose time has come. Toron- 2019. Accessed 6 February 2020. www2.gov.bc.ca/ in youth: A population-based survey. CMAJ 2008;178: to, ON; 2013. Accessed 5 May 2020. www.oha.com/ assets/gov/birth-adoption-death-marriage-and 306-312. Documents/Local%20Health%20Hubs%20for% -divorce/deaths/coroners-service/child-death 17. Skovlund CW, Kessing LV, Mørch LS, Lidegaard Ø. Increase 20Rural%20and%20Northern%20Communities.pdf. -review-unit/reports-publications/youth in depression diagnoses and prescribed antidepressants 28. Friesen E. The landscape of mental health services in _suicide_drp_report_2018.pdf. among young girls. A national cohort study 2000–2013. rural Canada. Univ Toronto Med J 2019;96:47-52. 12. Statistics Canada. Dictionary, census of population. Nord J Psychiatry 2017;71:378-385. 29. Jong M, Mendez I, Jong R. Enhancing access to care Ottawa, ON; 2016. Accessed 20 December 2019. www12 18. HealthLink BC. Health Canada and FDA advisories for in northern rural communities via telehealth. Int J Cir- .statcan.gc.ca/census-recensement/2016/ref/dict/ antidepressants. Victoria, BC; 2018. Accessed 11 Febru- cumpolar Health 2019;78:1554174. az1-eng.cfm. ary 2020. www.healthlinkbc.ca/health-topics/zu1129.

170 BC Medical Journal vol. 63 no. 4 | May 2021 BCMD2B

Intergenerational housing as a model for improving older-adult health

Housing options that promote connections between generations should be implemented as a means of providing benefits at both an individual and societal level.

Raiya Suleman, BHSc, Faizan Bhatia, BHSc

Abstract: As the older-adult population in Cana- Additionally, it is expected that there will be the impact on seniors. It also stated that hous- da increases, it is imperative that there be adequate over 5.5 million Canadians over the age of 80 ing was a “key component of fighting social and appropriate older-adult housing available. in 2068, compared to 1.6 million in 2018.1 This exclusion,” but highlighted that housing for Housing is a social determinant of health and is situation requires considerable thought and seniors was not a priority for most municipali- implicated in various health outcomes. Addition- action from the Canadian health care and po- ties in BC.8 The literature on loneliness among ally, a person’s living situation is interlinked with litical systems. older adults living in care facilities is also scarce; loneliness and social isolation, for which older A growing challenge among the older-adult however, one study explored loneliness in senior adults are at higher risk. Loneliness in older adults community is housing, and it is exacerbated housing communities and found that 42.7% of is correlated with a decline in function, lower self- by age-related issues such older adults living in these reported health scores, and overall mortality. One as social isolation, acces- Across studies, communities were mod- way to address these challenges in BC is with an sibility concerns, and so- loneliness among older erately lonely and 26.6% intergenerational housing model, where older cioeconomic factors. Of were severely lonely, using adults live in communities that promote ties with particular relevance is adults is shown to the Hughes scale.9 Across younger generations. Several intergenerational social isolation, which is have negative health studies, loneliness among programs exist worldwide, and they have signifi- defined as “a quantifiable consequences. older adults is shown to cant benefits for all involved. Intergenerational method of reduced social have negative health con- housing projects are gaining traction in Canada network” and is directly sequences. For example, and can serve as a method of improving the health related to loneliness, which is the perceived loneliness is correlated with a decline in func- and well-being of older adults while providing lack of a social network.2,3 Social isolation is a tion with activities of daily living, negatively benefits to society at large. prevalent issue among older adults, who are at impacting subjective health and increasing the higher risk due to the loss of family members risk of conditions such as depression, inconti- Background and geographical distancing.4 A longitudinal nence, hypertension, and vision impairment, The older-adult population in Canada is pro- cohort study by Perisonnoto and colleagues de- as well as overall mortality.5,9-12 It is clear that jected to continue expanding over coming de- termined that approximately 18% of individuals social isolation, and consequently, senior hous- cades. As of 2018, individuals age 65 and older over the age of 60 live alone, with 43% of sub- ing, are public health issues. Intergenerational made up 17.4% of the Canadian population. jects reporting that they feel lonely.5 Similarly, housing models serve as a potential solution to Projections estimate that by 2068, this percent- the Canadian National Seniors Council esti- address these concerns and help mitigate the age will grow to between 21.4% and 29.5%.1 mate that approximately 50% of people over the consequences associated with social isolation. age of 80 report feelings of loneliness.6 While the BC government recognizes the importance Senior housing models Ms Suleman and Mr Bhatia are fourth- of social and intergenerational connections and Several models of housing for older adults exist year students in the Faculty of Medicine their ties to mental and physical health, lim- nationwide, together creating tiers for delivery at the University of British Columbia. ited initiatives exist that target social isolation.7 of care that can be used based on an individual’s Additionally, the 2019 BC Centre for Disease specific needs. In general, these tiers include This article has been peer reviewed. Control report on social isolation discussed independent living, assisted living, long-term

BC Medical Journal vol. 63 no. 4 | May 2021 171 BCMD2B care, and hospice care, with respite care serving Intergenerational programs compared seven studies on intergenerational as a temporary option at almost all levels to pro- Existing intergenerational programs demon- programs, five of which showed mixed or posi- 27 vide caregiver relief. Independent care options strate an improvement in seniors’ health and tive outcomes for older adults. Importantly, involve minimal professional assistance, while well-being, suggesting a similar benefit would Hawkley and colleagues described that loneli- assisted living is suited for older adults who are be realized through intergenerational housing. ness can be alleviated, with one method being 24 able to make decisions but require support due One study conducted in Japan noted that older through increased socialization. 13 to physical and functional health challenges. adults who actively participated in an intergen- Long-term care is designated for medically erational program that involved regularly read- Benefits to society complex patients who require 24-hour nursing ing to school-age children over an 18-month Beyond the direct effects of improving the 1,3 care Hospice care is for patients who are at period reported improved subjective health health of older adults, intergenerational pro- end of life and require symptom management, and social networks compared to controls.22 gramming can lead to beneficial outcomes 14 and it is one of many palliative care options. A follow-up study based on this program was for society as a whole. For example, programs Intergenerational housing facilities could conducted 7 years later and demonstrated that that paired older adults with youth led to an 28 employ a uni- or multi-tiered approach to the control group had higher odds of having increased sense of trust and social capital. older-adult housing, depending on commu- decreased intellectual capacity as well as lower Additionally, such programming promotes in- nity needs and available resources. The premise levels of interactions with children.23 Addi- tergenerational ties and leads to an increased of intergenerational housing is that seniors’ tionally, at follow-up, the intervention group sense of community. This may have a cyclical needs are met in a similar way to the hous- demonstrated higher levels of physical function effect that ultimately decreases social isolation. ing options mentioned above, with the added related to fine motor skills, as measured through The direct relationship between loneliness and opportunity to reside with or among younger functional reach and grip strength.23 Functional depression is of note as depression costs the individuals who do not require these services. limitations are also a risk factor for loneliness; Canadian health care system $32.3 billion in 29 The BC-based company Happipad is a hous- therefore, intergenerational programs may help GDP annually. Although the financial ramifi- ing solution that frequently facilitates inter- address this underlying issue.24 cations of loneliness are not the primary driver 15 generational housing. Through its website, Another study in Japan consisted of explor- for promoting intergenerational programs, the Happipad often connects seniors looking for ing the impacts of participating in a weekly cost is substantial. Vasiliadis and colleagues social connections and additional income to intergenerational day program that paired se- state that the excess annual adjusted cost of younger tenants looking for affordable hous- niors with school-age children for 6 months.25 depression in seniors in Canada in 2006 was 15 30 ing. Purpose-built intergenerational-housing The study noted that a subgroup of seniors who $27.4 million. As well, the cost of managing spaces also exist in Canada, such as the newly reported higher scores on a depression scale chronic depression is estimated to be twice that 31 established Generations facility in Calgary, at enrolment showed a significant decrease in of hypertension and diabetes combined. With which integrates assisted, long-term, and pal- depressive symptoms after participating in the these statistics, we can start to appreciate the liative care in a multigenerational environ- program.25 A randomized trial with a similar worldwide economic impact of tackling geri- 16 ment. Similarly, Harbour Landing Village program was conducted in the United States, atric mental health with reduced social isola- in Regina is a care centre for older adults that which involved older adults volunteering in a tion and loneliness through intergenerational promotes personalized care and intergenera- local elementary school for 15 hours per week.26 housing. 17 tional activities. Similar housing schemes are This program yielded positive outcomes for The benefits of intergenerational hous- seen worldwide. For example, the Netherlands participants in the intervention group when ing also extend to the rest of the population. has housing plans in which students are of- compared to the control group.26 Specifically, 4 These include reduced housing costs for stu- fered free accommodation provided they spend to 8 months after completing the program, older dents through housing incentives and reduced 30 hours each month with their older-adult adults in the intervention group showed signifi- caregiver burnout as a result of the added sup- 18 housemates. In Fujisawa, Japan, Aoi Care cant improvement in physical activity, strength, port network in intergenerational programming houses elderly people with dementia, and is and cognitive ability.26 They also reported an and housing initiatives. The latter is particularly unique in that its residents decide on their daily increased ability to be able to turn to someone important as the Canadian General Social Sur- activities, frequently choosing to interact with for help, perhaps indicating a decreased sense vey for Caregiving and Care Receiving found children by playing ball or selling tea made at of social isolation.26 Furthermore, 80% of the that 34% of caregivers for their grandparents 19 the centre. Generally, studies show that living seniors returned to the program the following felt worried or distressed about their role and 32 and spending time with family, and specifically year, suggesting the program yielded a positive responsibilities as primary caregivers. caring for grandchildren, serve as protective experience for the participants.26 There are also beneficial effects for young- factors against older-adult loneliness, further While systematic reviews and meta-analyses er generations who participate in such pro- supporting the concept of intergenerational on the topic of intergenerational housing and grams. For example, children may benefit from 20,21 housing. programming are limited, one systematic review improved academic performance, positive

172 BC Medical Journal vol. 63 no. 4 | May 2021 BCMD2B

10. Kabátová O, Puteková S, Martinková J. Loneliness as a 23. Sakurai R, Yasunaga M, Murayama Y, et al. Long-term perceptions of the elderly, and enhanced skills 33,34 risk factor for depression in the elderly. Clin Soc Work effects of an intergenerational program on function- related to communication and empathy. Health Interventions 2016;7:48-52. al capacity in older adults: Results from a seven-year Additionally, as concluded in a literature review 11. Tilvis R, Laitala V, Routasalo P, et al. Suffering from loneli- follow-up of the REPRINTS study. Arch Gerontol Geri- conducted by Park in 2015, intergenerational ness indicates significant mortality risk of older people. atr 2016;64:13-20. programming has a positive effect on youth, and J Aging Res 2011;2011:534781. 24. Hawkley LC, Kocherginsky M. Transitions in loneliness 12. Hawkley L, Thisted R, Masi C, Cacioppo JT. Loneliness among older adults: A 5-year follow-up in the Na- demonstrates a reduction in feelings of anxiety predicts increased blood pressure: 5-year cross-lagged tional Social Life, Health, and Aging Project. Res Aging 35 and an improved sense of self-worth. analyses in middle-aged and older adults. Psychol Ag- 2018;40:365-387. ing 2010;25:132-141. 25. Kamei T, Itoi W, Kajii F, et al. Six month outcomes of an Conclusions innovative weekly intergenerational day program with older adults and school-aged children in a Japanese Intergenerational housing models should be urban community. Jpn J Nurs Sci 2011;8:95-107. further explored as a way of addressing old- Approximately 18% 26. Fried LP, Carlson MC, Freedman M, et al. A social model er adults’ concerns about housing and social of individuals over for health promotion for an aging population: Initial isolation in BC and Canada. Existing inter- evidence on the Experience Corps model. J Urban the age of 60 live Health 2004;81:64-78. generational programs benefit seniors through alone, with 43% of 27. Giraudeau C, Bailly N. Intergenerational programs: improved self-rated health scores, physical func- What can school-age children and older people ex- tion, and cognition. Additionally, such programs subjects reporting pect from them? A systematic review. Eur J Ageing have positive impacts on society at large, foster- that they feel lonely. 2019;16:363-376. 28. Murayama Y, Murayama H, Hasebe M, et al. The ing a sense of community, improving intergen- impact of intergenerational programs on social erational ties, cultivating economic gain, and capital in Japan: A randomized population-based cross- n increasing social capital. 13. Government of BC. Supportive housing and assisted sectional study. BMC Public Health 2019;19:156. living. Accessed 8 September 2020. www2.gov.bc.ca/ 29. Mortillaro N. Anxiety and depression cost the Cana- Competing interests gov/content/family-social-supports/seniors/housing/ dian economy almost $50 billion a year. Global News. None declared. supportive-housing-and-assisted-living. 2016. Accessed 6 April 2020. https://globalnews.ca/ 14. HealthLinkBC. Hospice palliative care. Accessed 8 Sep- news/2917922/anxiety-and-depression-cost-the tember 2020. www.healthlinkbc.ca/health-topics/ -canadian-economy-almost-50-billion-a-year. References aa114690. 30. Vasiliadis H-M, Dionne P-A, Préville M, et al. The excess 1. Statistics Canada. Population projections for Canada 15. Poole A. BC company helps seniors find young people healthcare costs associated with depression and anx- (2018 to 2068), provinces and territories (2018 to 2043). to share a home, expenses. CBC News. 2019. Accessed iety in elderly living in the community. Am J Geriatr Accessed 29 April 2020. www150.statcan.gc.ca/n1/ 1 January 2021. www.cbc.ca/news/canada/british Psychiatry 2013;21:536-548. pub/91-520-x/91-520-x2019001-eng.htm. -columbia/roomies-happipad-intergenerational 31. Depression among seniors in residential care. Cana- 2. Valtorta N, Hanratty B. Loneliness, isolation and the -housing-1.5244021. dian Institute for Health Information. 2010. Accessed health of older adults: Do we need a new research 16. Generations Calgary. Multi generational housing & com- 6 April 2020. https://secure.cihi.ca/free_products/ccrs agenda? J R Soc Med 2012;105:518-522. munity centre. Accessed 8 September 2020. https:// _depression_among_seniors_e.pdf. 3. Steptoe A, Shankar A, Demakakos P, Wardle J. Social iso- generationscalgary.com. 32. Turcotte M. Family caregiving: What are the conse- lation, loneliness, and all-cause mortality in older men 17. Harbour Landing Village. Accessed 8 September 2020. quences? Statistics Canada. Accessed 12 April 2020. and women. Proc Natl Acad Sci USA 2013;110:5797-5801. https://harbourlandingvillage.ca. www150.statcan.gc.ca/n1/pub/75-006-x/2013001/ 4. Cornwell B, Laumann E, Schumm L. The social con- 18. Reed C. Dutch nursing home offers rent-free hous- article/11858-eng.htm. nectedness of older adults: A national profile. Am So- ing to students. PBS NewsHour. 2015. Accessed 25 33. Chorn Dunham C, Casadonte D. Children’s attitudes and ciol Rev 2008;73:185-203. March 2021. www.pbs.org/newshour/world/dutch classroom interaction in an intergenerational educa- 5. Perissinotto C, Stijacic Cenzer I, Covinsky K. Loneliness -retirement-home-offers-rent-free-housing-students tion program. Educational Gerontol 2009;35:453-464. in older persons: A predictor of functional decline and -one-condition. 34. Jones ED, Herrick C, York RF. An intergenerational group death. Arch Intern Med 2012;172:1078-1083. 19. Schouwstra J. Innovative intergenerational care in benefits both emotionally disturbed youth and older 6. Government of Canada. Report on the social isolation Fujisawa, Japan. Together Old and Young. 2017. Ac- adults. Issues Ment Health Nurs 2004;25:753-767. of seniors. 2014 Accessed 8 September 2020. www cessed 6 April 2020. www.toyproject.net/2017/04/ 35. Park A. The effects of intergenerational programmes .canada.ca/en/national-seniors-council/programs/ innovative-intergenerational-care-in-fujisawa-japan. on children and young people. Int J School Cognitive publications-reports/2014/social-isolation-seniors/ 20. Ng CF, Northcott HC. Living arrangements and loneli- Psychol 2015;2:1-5. page05.html. ness of South Asian immigrant seniors in Edmonton, 7. Government of British Columbia. Social connections. Canada. Ageing Soc 2015;35:552-575. Accessed 31 December 2020. www2.gov.bc.ca/gov/ 21. Tsai FJ, Motamed S, Rougemont A. The protective ef- content/family-social-supports/seniors/health-safety/ fect of taking care of grandchildren on elders’ men- active-aging/social-connections. tal health? Associations between changing patterns 8. Lubik A, Kosatsky T. Is mitigating social isolation a plan- of intergenerational exchanges and the reduction of ning priority for British Columbia (Canada) municipali- elders’ loneliness and depression between 1993 and ties? BCCDC, 2019. Accessed 31 December 2020. www 2007 in Taiwan. BMC Public Health 2013;13:567. .bccdc.ca/Our-Services-Site/Documents/Social 22. Fujiwara Y, Sakuma N, Ohba H, et al. REPRINTS: Effects _Isolation_Report_17Sept2019.pdf. of an intergenerational health promotion program for 9. Taylor H, Wang Y, Morrow-Howell N. Loneliness in older adults in Japan. J Intergenerational Relationships senior housing communities. J Gerontol Soc Work 2009;7:17-39. 2018; 61:623-639.

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BC Medical Journal vol. 63 no. 4 | May 2021 175 JCCs

A first-of-its-kind Canadian partnership for a stronger health care system

n BC, doctors have a unique opportunity a quality improvement approach to co-create are involved in PCN planning and in conver- to get involved with system transformation solutions and strengthen relationships. sations at the provincial, regional, and com- through the Joint Collaborative Commit- munity levels. Forty-three PCNs have started Itees ( JCCs)—a first-of-its-kind partnership in Enhancing surgical and obstetrical care implementation as of spring 2021. Read more at Canada between Doctors of BC and the BC In rural BC communities where surgical care https://gpscbc.ca/what-we-do/system-change/ government. The JCCs bring together doctors, is provided by family physicians with enhanced primary-care-networks. government, health authorities, patients and surgical skills or solo general surgeons, the Rural families, health professions, and other stake- Surgical and Obstetrical Networks (RSONs) Coordinating surgical optimization holders to improve access to care by centring Initiative stabilizes, supports, and enhances Doctors are working with health authorities it on patients and families, building physician the delivery of surgical and obstetrical care to and facilities to improve assessment and man- capacity, and coordinating system services. local populations. The initiative is based on a agement of patients in need of surgery. The Through their Physician Master Agreement, five-pillar framework: scope and volume, remote Surgical Patient Optimization Collaborative Doctors of BC and the BC government allocate presence technology, clinical coaching, con- (SPOC) addresses the need for a coordinated funding to four committees that each have a tinuous quality improvement, and evaluation. approach to optimize or prehabilitate patients distinct focus and mandate: RSONs build on local, regional, and provincial for surgery. Prehabilitation can reduce adverse • Joint Standing Committee on Rural Issues: relationships to enhance the care provided by events during a surgery, improve outcomes and Enhances physician services in rural and and between teams. Teams include members recovery for patients, and increase patient and remote areas. of interdisciplinary OR and maternity teams caregiver satisfaction. • General Practice Services Committee: supported by a local community coordinator Since May 2019, SPOC has worked on Strengthens primary and community care. and with support from RCCbc. These networks developing a sustainable process that enables • Shared Care Committee: Improves collabo- are supported in Creston, Fernie, Golden, Ha- patients to optimize different components of ration between family doctors and specialist zelton, Port Alberni, Revelstoke, Smithers, and their health (e.g., diet, smoking, anemia, physi- doctors. Vanderhoof, and are in development in Powell cal activity) in preparation for an elective pro- • Specialist Services Committee: Engages River and Sechelt. Read more at https://enews cedure. To date, the collaborative has formed specialist doctors to collaborate, lead quality .rccbc.ca/tag/rson. multidisciplinary surgical prehabilitation teams improvement, and deliver quality services. in 15 hospitals, created a resource guide for Work of the JCCs is grounded in the In- Establishing team-based care networks caregivers to help implement prehabilitation stitute for Healthcare Improvement’s (IHI) Physicians in divisions of family practice are practices, and improved communication be- principles of quality improvement and framed working with health authority and community tween family doctors, surgeons, and patients. by the IHI’s Triple Aim.1 JCC funding and sup- partners to establish primary care networks SPOC is scheduled to complete in May 2021. It port enables divisions of family practice, medical (PCNs) through 39 regional collaborative is anticipated that the prehabilitation processes staff associations, and the Rural Coordination partnerships. A PCN is a team of health care initiated by the collaborative will be integrated Centre of BC (RCCbc) to take a grassroots providers made up of doctors and other health into routine surgical practices in BC. Read more approach to enhance patient care and improve care professionals who work together to pro- at https://sscbc.ca/programs-and-initiatives/ professional satisfaction for doctors. Through vide primary care to patients in a geographi- transform-care-delivery/surgical-patient the JCCs, doctors engage and lead in taking cal area. The foundation of the PCN is the -optimization-collaborative-spoc-0. patient medical home, a community practice where patients get the majority of their care Spreading and accelerating health This article is the opinion of the Joint with an emphasis on longitudinal relational care improvements Collaborative Committees (JCCs) and continuity and a team-based approach to care. Spread Networks engage family and specialist has not been peer reviewed by the BCMJ While the focus is on primary care, special- physicians, communities/divisions, and partners Editorial Board. ists have an important role within PCNs. They Continued on page 178

176 BC Medical Journal vol. 63 no. 4 | May 2021 bcCDC

Potent sedatives in opioids in BC: Implications for resuscitation, and benzodiazepine and etizolam withdrawal

ortality due to drug overdose has Dependence to and withdrawal from ben- include hypotension, bradycardia, and respira- risen to unprecedented levels in zodiazepines or etizolam may occur after expo- tory depression. British Columbia. In 2020, 1724 sures of only a few weeks.3 Increasing exposure Benzodiazepine adulteration makes the re- people died of drug overdose compared to 984 to benzodiazepines puts many people who use suscitation of patients with illicit drug overdose M 1 people in 2019. drugs at risk for withdrawal symptoms (e.g., complex. The mainstay of overdose treatment is There has been a significant increase in agitation, sleeplessness, autonomic instability), monitoring and supportive care. As respirato- the proportion of opioid samples containing which may be difficult to ry depression is the major strong sedatives. These sedatives include ben- clinically differentiate cause of opioid overdose zodiazepines, etizolam, and xylazine. In Janu- from opioid withdrawal or As respiratory mortality and morbidity, ary 2021, benzodiazepines were found in 20% stimulant toxicity. With- depression is the patients’ respiratory sta- of opioid samples checked by the BC Centre drawal from benzodiaz- major cause of opioid tus should be monitored. on Substance Use and 50% of samples from epines and etizolam has Simply measuring a pa- overdose mortality and the Vancouver Island Drug Checking Project. been increasingly reported tient’s respiratory rate may Particularly concerning is that benzodiazepines across BC over the past 6 morbidity, patients’ be an unreliable estimate were detected in 50% of illicit drug toxicity months. respiratory status of respiratory function; deaths in BC in December 2020 and January The effects of both should be monitored. therefore, monitoring 2021.2 benzodiazepines and eti- oxygen saturation and Benzodiazepines and etizolam enhance zolam can be reversed end tidal carbon dioxide the action of the inhibitory neurotransmitter, with flumazenil. However, flumazenil should should be instituted if available. Hypoventila- gamma aminobutyric acid. Patients with ben- not be used in the treatment of suspected ben- tion should be treated with respiratory support. zodiazepine overdoses may have profound CNS zodiazepine or etizolam overdose because it Hypoglycemia may occur in opioid overdose, so depression. Symptom onset occurs in 0.5 to is associated with ventricular dysrhythmias clinicians should check serum glucose.5 2 hours. Symptom duration can vary depending and seizures. Flumazenil can also precipi- Naloxone is a competitive opioid antagonist on the agent and dose; generally, patients with tate benzodiazepine or etizolam withdrawal. that is effective in reversing opioid overdose. etizolam overdoses will be sedated for many If seizures occur after the use of flumazenil, In cases where opioid overdose is suspected, hours. Also of note is that urine toxicology will they can be very difficult to treat.4 Xylazine is lay and health care responders should give not detect all benzodiazepines. Point-of-care a partial alpha-2-adreneric agonist pharma- naloxone to patients with hypoventilation or screens in BC will detect etizolam but their cologically related to clonidine. Toxic effects who are unable to protect their airway. Where reported sensitivity is 50% to 70%. It is, there- fore, important to treat patients clinically if benzodiazepine toxicity is suspected. Additional resources from the BCCDC • Summary sheet for health professionals. Benzodiazepines found in opioids in BC. https://towardtheheart.com/resource/benzos-in-opioids-in-bc/open. • Fact sheet: Etizolam in BC’s illicit drug market. https://towardtheheart.com/resource/ etizolam-in-bc-illicit-market/open This article is the opinion of the BC Centre • Position statement: Observed consumption services. www.bccdc.ca/resource-gallery/ for Disease Control and has not been Documents/Statistics%20and%20Research/Statistics%20and%20Reports/Overdose/ peer reviewed by the BCMJ Editorial Final_OCSStatement_June2019.pdf Board.

BC Medical Journal vol. 63 no. 4 | May 2021 177 JCCs bcCDC

Continued from page 176 benzodiazepines are adulterants in an illicit —Jesse Godwin, MD Medical Toxicologist, BC Drug and Poison opioid overdose, patient sedation may be en- to collectively improve coordination of care Information Centre hanced and patients’ response to naloxone may for priority populations locally and provin- —Jessica Moe, MD be incomplete. However, responders should cially. A maternity network was the first to Assistant Professor, Department of still administer naloxone, as it will reverse be created in 2017 to improve interprofes- Emergency Medicine, UBC opioid-related toxicity. Naloxone should be sional collaboration and delivery of maternity titrated to effect, and opioid withdrawal pre- care in BC. The network has since grown to References cipitated by naloxone should be avoided. At 1. BC Coroners Service. Illicit drug toxicity deaths in BC involve 25 communities/divisions, and is tran- the BC Drug and Poison Centre, we recom- Jan 1, 2011 to February 28, 2021. Accessed 30 March sitioning to a community of practice. Other mend the following naloxone regimen if there 2021. www2.gov.bc.ca/assets/gov/birth-adoption Spread Networks cover adult mental health is clinical suspicion of opioid overdose: 0.04 to -death-marriage-and-divorce/deaths/coroners and substance use, chronic pain, coordina- -service/statistical/illicit-drug.pdf. 0.1 mg initially, followed by subsequent doses 2. BC Coroners Service. Illicit drug toxicity type of drug tion of care for older adults, and palliative (q2–3 min): 0.4 mg, 0.4 mg, 2.0 mg, 4.0 mg, data (data to Jan 31, 2021). Accessed 30 March 2021. care. Read more at https://sharedcarebc.ca/ then 10 mg.6 If ongoing sedation persists due www2.gov.bc.ca/assets/gov/birth-adoption-death our-work/spread-networks. to prolonged effects of concurrent benzodi- -marriage-and-divorce/deaths/coroners-service/ Learn more at www.CollaborateOnHealth statistical/illicit-drug-type.pdf. n azepines, patients should be monitored until 3. O’Connell CW, Sadler CA, Tolia VM, et al. Overdose BC.ca. —Ahmer Karimuddin, MD they are safely ventilating and their level of of etizolam: The abuse and rise of a benzodiazepine consciousness returns. analog. Ann Emerg Med 2015;65:465-466. SSC Co-chair Please contact the BC Drug and Poison 4. An H, Godwin J. Flumazenil in benzodiazepine over- —Anthon Meyer, MD dose. CMAJ 2016;188:E537. GPSC Co-chair Information Centre in all suspected cases. We 5. Boyer EW. Management of opioid analgesic overdose. are pleased to work with you in the manage- N Engl J Med 2012;367:146-155. n ment of these complex cases. 6. Godwin J, Kestler A, DeWitt C, Purssell R. Opioid Reference —Roy Purssell, MD overdose best practice guidelines. British Columbia 1. Institute for Healthcare Improvement. The IHI Triple Aim. Accessed 15 March 2021. www.ihi.org/Engage/ Medical Lead, BC Drug and Poison Drug and Poison Information Centre. Accessed 30 Initiatives/TripleAim/Pages/default.aspx. Information Centre, BCCDC March 2021. www.dpic.org/sites/default/files/pdf/ OpioidGuidelines_1Mar2017.pdf. —Jane Buxton, MBBS Medical Lead for Harm Reduction, BCCDC

Available for streaming on all podcast platforms PUTTING INDIGENOUS CULTURAL SAFETY INTO PRACTICE with guests Dr Terri Aldred and Len Pierre

A Doctors of BC Podcast

178 BC Medical Journal vol. 63 no. 4 | May 2021 worksafebc

Medical advisors reaching out to community physicians: A new WorkSafeBC initiative

edical advisors are physicians who recovery and some form of return to work. We • Earlier clarification of diagnoses, medical work at WorkSafeBC to provide piloted this initiative in 2020 and have seen a restrictions, and treatment plans. medical reviews of injured worker positive impact from the medical advisor con- • Greater understanding of the role of medical Mclaims. They are your colleagues and are licensed necting with the injured worker’s physician. advisors and benefits of peer-to-peer col- with the College of Physicians and Surgeons of Medical advisors can offer support and guidance laboration among community physicians. BC. Many are accredited in sports or occupa- to community physicians on the claim process • Enhanced communication leading to effi- tional medicine, have training in mental health, and disability management, can expedite refer- cient engagements and a follow-up system and maintain clinical practices. They regularly with community physicians. enlist the expertise of physician specialists in The initiative aims to • Early discussion of expectations, return- orthopaedics, internal medicine, ophthalmology, provide and support to-work planning, and the identification of and psychiatry to support our case management barriers to returning to work. teams for the benefit of injured workers. excellent worker care • Targeted and early support for community In 2021, WorkSafeBC medical advisors will along with timely and physicians with a focus on safe, durable, and reach out to community physicians earlier in safe return to work. timely return to work as part of treatment the claim process to assist with their patients’ plans. recovery and return to work. There is consensus • Early identification of the absence of a pri- about the value of work for injured workers—it’s rals for imaging or specialist consultations, and mary care provider, allowing for the mitiga- healthy, it contributes to recovery, and it leads can promote collaboration between community tion of this common challenge. to better health outcomes.1 physicians and WorkSafeBC. Ultimately, the We thank you in advance for your engage- Yet not all injured workers reap the health initiative aims to provide and support excel- ment when one of our medical advisors contacts benefits of work. Some recover at home for ex- lent worker care along with timely and safe you. Typically, your commitment will be 5 to 10 tended periods—away from work and isolated return to work. minutes, and you may bill fee code 19930 for from co-workers and regular routines—placing For the worker, this early review can help your time. To learn more, or to discuss a patient them at higher risk of suicide, obesity, heart at- address outstanding medical issues in a timely who was injured at work, feel free to contact a tack, depression, and substance abuse.2 and efficient manner, provide for a medically medical advisor by calling 1 855 476-3049. n The Early Medical Advisor Involvement supported return to work, and keep the worker —Janice Mason, MD, Dip. Sport Med. (CASEM) process involves reviewing all claims without connected with the workplace and colleagues. Manager, Medical Services, WorkSafeBC a return-to-work plan 8 weeks after the date The community physician has an opportunity —Alfredo Tura, MD, CCFP, FCFP, ACBOM of injury. The medical advisor will contact the for enhanced collaboration with WorkSafeBC; Medical Advisor, WorkSafeBC, attending physician to discuss opportunities for this integrated sharing of information opti- Clinical Associate Professor, UBC additional treatment/rehabilitation, obstacles mizes care and access to resources for their pa- —Peter Rothfels, MD to the patient’s recovery, and potential work tient, supports patient recovery, and promotes a Chief Medical Officer, WorkSafeBC opportunities if the patient is not yet ready to greater understanding of the benefits of return References return to regular duties. to work as part of the treatment plan. 1. Waddell G, Burton AK. Is work good for your health This allows medical advisors to collaborate For the employer, an appropriate earlier and well-being? London, UK: The Stationery Office; with community physicians about how Work- return to work helps their employees remain 2006. Accessed 18 March 2021. https://assets.publishing .service.gov.uk/government/uploads/system/uploads/ SafeBC can assist, with the goal of functional connected with the workplace. Many employers attachment_data/file/214326/hwwb-is-work-good can accommodate medical restrictions, offer- -for-you.pdf. 2. Felhaber T. The risks of worklessness. This changed This article is the opinion of WorkSafeBC ing light or modified duties while an injured worker is recovering. To date, we have seen the my practice. 20 September 2017. Accessed 18 March and has not been peer reviewed by the 2021. https://thischangedmypractice.com/the-risks BCMJ Editorial Board. following outcomes: -of-worklessness.

BC Medical Journal vol. 63 no. 4 | May 2021 179 News We welcome news items of less than 300 words; we may edit them for clarity and length. News items should be emailed to [email protected] and must include your mailing address, telephone number, and email address. All writers should disclose any competing interests.

and looks forward to the return of live music and theatre performances so that she may con- tinue to indulge her passion for the arts. The winning article and blog post were se- lected by BC physician and regular contributor to the BCMJ, Dr George Szasz, in lieu of the Editorial Board. An Editorial Board member had competing interests with several of the eligible articles; therefore, the Board elected to defer to an external judge to ensure an im- partial result. Dr Szasz found the candidates’ work to be excellent, clever, and sometimes even touching. Each article was informative, interesting, and wildly varied in content, while the blog posts were short, focused, and written in a conver- sational manner, making it a difficult task to Jillian Lin Paige Dean choose a first among equals. In the end, Dr Szasz found Jillian Lin’s essay to represent 2020 MacDermot writing prize winners the most significant achievement in medical writing. He was grabbed by her touching pre- The 2020 J.H. MacDermot Prize for Excel- children’s health, mental health, social medicine, sentation about a medical student’s journey in lence in Medical Journalism: Best article or and palliative care. understanding death, and the description of essay was awarded to Jillian Lin for her article The 2020 J.H. MacDermot Prize for Ex- her halting and fearful approach to death and “Palliative care and legacy creation” [BCMJ cellence in Blog Writing: Best blog post was her evolving courage to be involved with dying 2020;62:292-293]. awarded to Paige Dean for her post “Stay in- people. In the blog writers’ group, Paige Dean’s Jillian would like to thank both Betty and formed, stay safe: How to handle everyday post resonated for Dr Szasz. He felt her fear of her late aunt, who inspired the article, as well activities during the COVID-19 pandemic” inadequacy and insecurity when trying to offer as Dr Pippa Hawley for providing guidance [BCMJ.org, 28 June 2020]. factual health information to patients, and her on the Legacy Project. Jillian wrote this article Paige is in her final year of medical school at description of how she gained confidence made as a second-year UBC medical student. She is UBC and feels fortunate to have spent the past for a realistic blog post. now a third-year student going through clini- 4 years training in beautiful British Columbia, Congratulations to all authors. BC medical cal core rotations in the Vancouver-Fraser re- a place she proudly calls home. Although the students are encouraged to submit full-length gion. As she goes through her clinical rotations, past year has brought many changes, she found scientific articles and essays for publication con- she continues to learn from patient encounters great fulfillment by participating in this project sideration. Each year the BCMJ awards a prize and feels fortunate to be involved in caring for (Practical solutions for COVID-19 challeng- of $1000 for the best article or essay written another person’s well-being. Jillian aspires to es), which helped her navigate the uncertainty by a medical student in BC, and may award a be a resident physician in Canada when she brought about by COVID-19. Paige hopes to prize of $250 twice per year to the writer of the graduates in 2022. She is excited for the years spend her career providing holistic medicine as best blog post accepted for online publication to come and curious about what kind of physi- either a pediatrician or a family doctor. Outside in the preceding 6 months. For more infor- cian she will become. Her professional interests of medicine, Paige is an avid runner, enjoys ex- mation about the prizes, visit www.bcmj.org/ are broad but consistently include youth and ploring the great outdoors by hiking and skiing, submit-article-award.

180 BC Medical Journal vol. 63 no. 4 | May 2021 news

Doctors of BC insurance team to ensure all insurance applications and queries • Access individual insurance certificates working remotely to support were handled confidentially and in a timely outlining coverage and plan details online your needs manner. in the members area of the Doctors of BC Here are some of the ways physicians can website. With the onset of COVID-19 pandemic now interact virtually with Doctors of BC for • Pay invoices online, or set up automatic a year ago, Doctors of BC implemented a their insurance needs: direct debit payments (complete a banking work-from-home protocol to keep staff and • Schedule appointments with insurance ad- change form to begin). members safe and healthy. Simultaneously, phy- visors via a 24/7 online booking system. • Submit forms electronically to change or sicians recognized the need for insurance to • Use enhanced videoconferencing tech- add beneficiaries on your life insurance or protect their assets and provide peace of mind nology via your tablets, desktops, and mo- accidental death and dismemberment poli- to their family, and demand for our services bile devices to stay connected on a personal cies or to add new dependants or office staff increased significantly. level. to your health and dental plan. For the Doctors of BC Insurance Depart- • Complete and sign most applications dig- We look forward to seeing you again in per- ment, this meant shifting our 22-person team itally (eliminating the need to print and son, but until then, we are a phone call, email, of advisors, administrators, and support staff manually sign). or Zoom meeting away for all your insurance from a paper-based office environment to a • Access higher limits of insurance coverage needs. fully remote setting. Doctors of BC worked without providing blood or urine tests, —Kerri Farrell closely with the insurance carriers and our IT thanks to updated underwriting guide- Project Coordinator, Members’ Products and team to ensure continuous and seamless sup- lines. (Please ask your insurance advisor Services port during this time of uncertainty. As a result, for details.) digital processes were developed and enhanced

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BCMJ Blog: New episode of DocTalks: Physician burnout during COVID-19 Reports of physician burnout are increasing as BC doctors work to meet the Your 2019 mini profile is now available on of ICBC and WorkSafeBC. The profiles are unprecedented demands generated by the the Doctors of BC website. The profile pro- an accurate reflection of claims submissions COVID-19 pandemic. vides statistics based on the MSP payments and payments made in the claims record that Read the post: bcmj.org/blog/new-episode made to you for the services you provided in identified you as the physician who provided -doctalks-physician-burnout-during-covid-19 the 2019 calendar year, including any settle- the service, or in the case of referred services, ments or retroactive payments issued as of 31 identified you as the referring practitioner. March 2020. This allows you to monitor your Visit www.doctorsofbc.ca/news/2019- billings in comparison to your peer group mini-profiles-now-available for more in- and address any potential issues quickly and formation. If you have questions or need early. Understanding the flags on your profile, help understanding your profile, contact which could put you at higher risk for an Juanita Grant at [email protected] or audit, can help you determine if you need to 604 638-2829 (toll-free 1 800 665-2262). make changes to your billings and alert you to —Tara Hamilton a potential issue that could be avoided. Also Advisor, Audit & Billing, Economics, Advocacy & Negotiations in the data are claims paid by MSP, on behalf Follow us on Facebook for regular updates

BC Medical Journal vol. 63 no. 4 | May 2021 181 news

Improvements to Rural Retention Program encouraging physicians to practise in rural communities

The Joint Standing Committee on Rural Is- sues ( JSC), a partnership of Doctors of BC and the BC government, has announced sig- nificant changes to the Rural Retention Pro- gram (RRP) that will increase eligibility for incentives and benefits and stabilize funding to better recruit and retain physicians into practices in rural communities. The RRP of- fers incentives and benefits to encourage doc- tors to establish and maintain practices and connections in rural communities. The pro- gram is designed to enhance the supply and stability of physicians in rural communities as defined by the Rural Subsidiary Agreement (RSA). The changes reflect feedback from Changes to the Rural Retention business cost premium payments as per extensive consultations with rural physicians, Program the recent Physician Master Agreement. communities, and health authorities as part Effective 1 April 2021, the changes are: An increase will be added to rural phy- of a review of the program. This completes • A temporary reduction of the RRP in- sicians’ RRP flat fee payment disbursed the first phase of the review. come eligibility threshold. The JSC rec- through the health authority on behalf ognizes that COVID-19 has impacted of the JSC. Consultations professional practice. To broadly support • The minimum point threshold to be Recognizing that the eligibility criteria had physicians whose income may have been eligible for full rural benefits has been been largely unchanged since the program impacted, the income requirement for eli- reduced from 6.0 to 1.5 points. The com- started nearly 20 years ago, the JSC under- gibility of the RRP flat fee in 2021/22 has munities falling between 1.5 and 14.99 took a comprehensive 3-year review of the been reduced from $75 000 to $65 000. points will now be considered “C” des- RRP starting in August 2018. Facilitated by • New and retroactive eligibility for phy- ignated communities and will be eligible the Rural Coordination Centre of BC, nearly sicians on parental leave or planning for those benefits. This means that more 600 rural physicians were consulted via fa- medical leave are available. Until now, communities will be eligible for RRP cilitated dialogue, webinars, and a provincial physicians on parental or medical leave payments for their physicians, and they survey. In addition, medical and administra- were not eligible to receive RRP pay- will be able to continue to receive other tive leaders in each rural health authority, ments. To support physicians to stay in benefits under the RSA. community groups, subject matter experts, the community, the changes mean that • To help mitigate year-to-year variations and other partners were consulted to develop physicians will be eligible for the RRP and uncertainties, and to appropriately recommendations. flat fee payment and their earned RCME stabilize the community points, the JSC Feedback included suggestions to address benefit for a period of 12 months, effec- will now implement point assessments the annual fluctuation of rural points in some tive retroactively to 1 April 2020. using a five-year rolling average. This communities, to ensure the RRP remains a • The Rural Business Cost Modifier will ease the year-to-year fluctuations, relevant incentive program including coverage (RBCM) is being introduced to support stabilizing payments and benefit levels for medical or parental leaves, and to create physicians who reside and practise in rural in communities. equity with the business cost premium. communities. This change aligns pay- For questions or inquiries, contact rural- The JSC agreed to hold the points con- ments to rural physicians with doctors [email protected]. stant while it conducted the review. in urban areas who are eligible for the

182 BC Medical Journal vol. 63 no. 4 | May 2021 news

Fast-tracked vaccinations for the vulnerable: Communicating with patients Doctors of BC has prepared a series of scripts and articles for doctors to raise awareness among their patients on how to determine if they are eligible for early vac- cines designated for people who are clini- cally extremely vulnerable, and, if they are, how to register for their vaccinations. The information is available on the Doctors of BC website at www.doctorsofbc.ca/news/ bc-physicians-how-communicate-patients -about-fast-tracking-vaccinations-vulner- able (login required).

The BC Medical Journal is Do you have an idea? written by physicians like you. We welcome your contributions, from letters to scientific papers and everything in between.

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BC Medical Journal vol. 63 no. 4 | May 2021 183 CME calendar Rates: $75 for up to 1000 characters (maximum) plus GST per month; there is no partial rate. If the course or event is over before an issue of the BCMJ comes out, there is no discount. Deadlines: Online: Every Thursday (listings are posted every Friday). Print: The first of the month 1 month prior to the issue in which you want your notice to appear; e.g., 1 February for the March issue. The BCMJ is distributed by second-class mail in the second week of each month except January and August. Planning your CME listing: Advertising your CME event several months in advance can help improve attendance; we suggest that your ad be posted 2 to 4 months prior to the event. Ordering: Place your ad at www.bcmj.org/cme-advertising. You will be invoiced upon publication. Payment is accepted by Visa or MasterCard on our secure online payment site.

PSYCHOLOGICAL PPE, PEER SUPPORT Activation Disorder: The Bowel Microbiome with protocols respecting current public health BEYOND COVID-19 and Other System Effects. To register and recommendations. Mindfulness in Medicine, a Online (Wednesdays) for more information visit https://ubccpd.ca/ meditation retreat for physicians, will be held at course/cme-on-the-run-2020-2021 or email Hollyhock on Cortes Island from 21–26 May. In response to physician feedback, the Phy- [email protected]. To find out more, or to register, please contact sician Health Program’s online drop-in peer Dr Mark Sherman at mark@livingthismoment support sessions, established 7 April, are now 18TH ANNUAL PEDIATRIC EMERGENCY .ca or go to www.livingthismoment.ca/events. permanently scheduled for Wednesdays at MEDICINE UPDATE noon. The weekly sessions are cofacilitated by Online, 14 May 2021 (Friday) GP IN ONCOLOGY EDUCATION psychiatrist Dr Jennifer Russel, and manager of Vancouver, 13–24 Sept 2021 (Mon–Fri) clinical services Roxanne Joyce, and are drop-in Join us for the 18th Annual Pediatric Emer- with no commitment required. The focus is gency Medicine update on Friday, 14 May. BC Cancer’s Family Practice Oncology Net- peer support, not psychiatric care. All partici- Registration includes access to the live virtual work offers an 8-week General Practitioner in pants have the option to join anonymously. event, all available materials, and access to the Oncology education program beginning with a To learn more about the sessions and the pro- post-event recording. Topics include 2020 Pe- 2-week introductory session every spring and gram, visit www.bcmj.org/news-covid-19/ diatric Resuscitation Guidelines, Pitfalls in fall at BC Cancer–Vancouver. This program psychological-ppe-peer-support-beyond-covid Mechanical Ventilation of Children in the ER, provides an opportunity for rural family physi- -19. Email [email protected] Latest in Management of Gastroenteritis, An- cians, with the support of their community, to for a link to join by phone or video. algesia and Sedation in the Agitated Child, strengthen their oncology skills so that they can Appendicitis and Testicular Torsion Path- provide enhanced care for local cancer patients CME ON THE RUN ways, MIS-C, Recognition and Stabilization and their families. Following the introductory Online, 2 October 2020–4 June 2021 of Children with Eating Disorder in the ER, session, participants complete a further 30 days (Fridays) Practice-Altering Articles, Latest on Pediatric of clinic experience at the Cancer Centre where Trauma, Commonly Misdiagnosed Rashes and their patients are referred. These are scheduled The CME on the Run sessions are offered on- Vascular Access in Children. To register and flexibly over 6 months. Participants who com- line. Registrants will receive links to go online plete the program are eligible for credits from before each session. Each program runs on for more information visit https://ubccpd.ca/ the College of Family Physicians of Canada. Friday afternoons from 1 p.m. to 5 p.m. and course/peder2021 or email [email protected]. Those who are REAP-eligible receive a sti- includes great speakers and learning materials. MINDFULNESS IN MEDICINE WORKSHOP/ pend and expense coverage through UBC’s Topics and dates: 4 June 2021 (Internal Medi- RETREAT Enhanced Skills Program. For more informa- cine). Topics include Short and Long Term Sys- Cortes Island, 21–26 May 2021 (Fri–Wed) tion or to apply, visit www.fpon.ca, or contact temic Effects of COVID-19, Current Role of Jennifer Wolfe at 604 219-9579. Labs and Imaging in the Assessment of Chest Please join us for a workshop/retreat focusing Pain, Insulin 101: When and How to Start in on the theory and practice of mindfulness-based Family Practice, A Rational Approach to He- stress management for physicians and other licobacter pylori Diagnosis and Management, health professionals. This powerful and popular Atrial Fibrillation: Management in the Office, program offers practical skills to navigate the Seropositive/Seronegative Arthritis: How to stresses and challenges of our work in order Assess and Treat Those Really Achy Joints, The to prevent burnout and build resilience and Place for Stem Cell Therapy and Plasma-Rich wellness into our personal and professional Protein in Current Medical Practice, Mast Cell lives. The program will take place in person

184 BC Medical Journal vol. 63 no. 4 | May 2021 Doctors are at the centre of everything we do. We understand the challenges unique to your profession. Let us simplify insurance and give you financial peace of mind.

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Guidelines for authors

he British Columbia Medical Journal is a and on the backlog of papers scheduled for publica- News. A miscellany of short news items, announce- general medical journal that seeks to con- tion. Manuscripts are returned only on request. The ments, requests for study participants, notices, and so tinue the education of physicians through BCMJ is posted for free access on our website. on. Submit suggestions or text to journal@doctors review articles, scientific research, and updates on ofbc.ca or call 604 638-2858 to discuss. Less than contemporaryT clinical practices while providing a 300 words. For all submissions forum for medical debate. Several times a year, the Avoid unnecessary formatting, as we strip all for- BCMJ presents a theme issue devoted to a particular matting from manuscripts. Clinical articles/case reports/ discipline or disease entity. Double-space all parts of all submissions. We welcome letters, blog posts, articles, and sci- survey studies Manuscripts of scientific/clinical articles and case entific papers from physicians in British Columbia Include your name, relevant degrees, email reports should be 2000 to 4000 words in length, and elsewhere. Manuscripts should not have been ad dress, and phone number. including tables and references. The first page of the submitted to any other publication. Articles are Number all pages consecutively. manuscript should carry the following: subject to copyediting and editorial revisions, but authors remain responsible for statements in the Opinions Title, and subtitle, if any. BCMD2B (medical student page). An article on work, including editorial changes; for accuracy of Preferred given name or initials and last name for any medicine-related topic by a BC physician-in- references; and for obtaining permissions. The cor- each author, with relevant academic degrees. responding author of scientific articles will be asked training. Less than 2000 words. The BCMJ also to check page proofs for accuracy. welcomes student submissions of letters and scien- All authors’ professional/institutional affiliations, The BCMJ endorses the “Recommendations for tific/clinical articles. BCMD2B and student-written sufficient to provide the basis for an author note the Conduct, Reporting, Editing, and Publication of clinical articles are eligible for an annual $1000 medi- such as: “Dr Smith is an associate professor in the Scholarly Work in Medical Journals” by the Inter- cal student writing prize. Department of Obstetrics and Gynaecology at national Committee of Medical Journal Editors Blog. A short, timely piece for online publication on the University of British Columbia and a staff (updated December 2016), and encourages authors bcmj.org. Less than 500 words. 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