TeleHealth Visits

Unfortunately we are not accepting new patients for Addiction Medicine care at this time. If you are a previous patient, please contact the clinic and we might be able to accommodate you. Please contact the clinic for details, at 647.295.5565 or Please do not include any personal medical information in your voicemail or email. She will get back to you by phone to discuss your situation and set up an appointment with me.

For my current patients, I am using Ontario Telehealth Network (OTN).

If you want to get set up for OTN before speaking with my assistant, you can review the process on this link to OTN. In order to see me on OTN, you need to use a browser on a laptop or computer, and I have been advised that Google Chrome works best.

If you would rather use your cellphone, you need to download 1 app prior to being able to see me: Pexip Infinity Connect.

Once you are set up, you will receive an invitation for a virtual visit. The instructions will be on the email, but if you have difficulty, please call my assistants, and they can help you resolve most issues.

Please READ THE CONSENT form prior to starting your visit. We will discuss this online at the beginning of your first session, but it would be great if you could read it prior to that. If you do not wish to proceed, please give us a call.

I hope you and those you care about are keeping safe in these times of COVID19. I look forward to seeing you online, and helping you achieve your goals regarding addictions and associated healthcare issues.

Please call us before coming in if you are a patient here and you think you might have COVID19.

IMPORTANT: Who Should Go to Their Nearest Emergency Department
People who have symptoms of upper respiratory tract infection (cough, sore throat, headache, muscle aches, fatigue, runny nose, and joint aches, and may also include nausea, diarrhea and stomach pains) and any of the following more severe symptoms:
Shortness of breath when walking, exercising, or at rest, which is unusual
Chest pain or discomfort
Weakness that impairs ability to carry out activities of daily living, such as showering, preparing meals, and dressing
Lethargy or drowsiness
Patients not well enough to take personal transportation, call 911
Symptomatic infants less than 6 months of age with fever and/or respiratory symptoms should always be assessed in the emergency department

If you think you are ill and might have COVID19, use the self assessment tool link to find out what you should do. OHIP coverage is not required to be seen at a COVID-19 Assessment Centre. The assessment is provided at no cost to the individual.

A number of dedicated assessment centres have been established across Toronto to facilitate assessment and testing. If you need to be assessed, here are the assessment centers.

HELP STOP THE SPREAD to yourself and others.

Hand Washing and not touching your face is the most important thing you can do to prevent getting infected.

Physical Distancing is also very important to not spreading COVID19. Some more information here.

An excellent source of information about COVID19

Fed Sanchez MD CCFP(AM)

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Tolerance and the Dangers of Self Tapering

Recently I heard a few patients tell me that they have been self tapering their Methadone dose.  They had been doing this by throwing out a small amount, each day, from their carries in an attempt to decrease the amount they are taking.  I feel that this is so dangerous that I wanted to let all my patients know the risks.  It all comes down to tolerance and safety.

Tolerance to a drug is how much the drug effect changes depending on how much of the drug you are using.  For example, if you use a lot of Heroin, you get used to it, and it does not have the same effect it used to.  In other words, your tolerance to Heroin increases the more you use it.  You need more of the drug to get the same effect over time.

The same happens with Methadone.  But the difference is that in the Methadone program, you try to deal with the tolerance that you have developed with other opiates like Heroin, Oxy, Percocets, Fentanyl, etc.  We try to get your dose of Methadone to the point where you can feel normal again.  You are not trying to get high on Methadone, so you do not end up chasing the dose higher and higher.  Once you stabilize on a Methadone dose, you are set.  You should not need to increase, or decrease, the dose.

The brain likes balance.  Tolerance is a result of the brain trying to get this balance.  When someone is increasing their Oxy dose to achieve a high, they are fighting with their brain’s natural tendency towards balance.  In the Methadone program, you are trying to achieve balance, and you are working with your brain to achieve the balance you need to feel normal once again.

Speed of tolerance is different for different effects of Methadone. Tolerance to pain control changes slowly. Tolerance to getting high changes fast.   The tolerance to stopping breathing changes very fast.  This is why you don’t stop breathing if you increase your dose slowly when you start the Methadone program.  In fact, that is why I insist on dose increases only every 3-4 days.

On the way down, the same thing happens.  Your tolerance to stopping breathing lowers faster than the other tolerances.  This means that if you spend a few days at a lower dose, and then raise it again, you can stop breathing.  That is why your dose has to be lowered if you miss 3 doses, and you have to restart the program if you miss 4 or more.  It is all about safety.

Now, if you self taper yourself down, a few things can happen.  For one, you really don’t know how much you are decreasing your dose.  You may be going down too fast one day, and less on another.  Just watch your pharmacist prepare your dose carefully and see how hard it is for them to get your dose just right.  You cannot do it yourself safely.  Also, if I don’t know about it, I cannot monitor you for dangerous effects.  You will also be having withdrawals, and not telling me about them.  Again, I will not be able to help you.

When you do your supervised doses, the pharmacist will give you your regular dose, which will be higher than your tapered dose.  This is dangerous, because the tolerance to stopping breathing, and possibly dying, changes faster than the tolerance to withdrawal issues.  So that one dose can in fact be dangerous.

Here is a very dangerous situation:  Imagine that you are self tapering.  You run into a dosing wall, and feel the withdrawals every day.  You decide that you give up, and start taking your regular dose again.  Doing this can kill you.

Here is the bottom line: DON’T SELF TAPER.  If you want to decrease your dose, tell me.  I may agree that it is time to lower your dose.  On the other hand, I might suggest that you don’t decrease your dose, and would explain my reasons for feeling that you are not ready.   But I will never stop you from lowering your dose.  If you insist on lowering your dose, I will do it, even if I disagree.  This way, I will know what is going on in your dosing, and  I can help you stay out of trouble if things don’t work out as well as you would like.  Remember, it is all about safety.

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Many people find that boredom is a major trigger to using drugs, even if they may be at the right Methadone or Suboxone dose. You might take drugs once or twice a week. You might be bored and don’t know what to do, so you take drugs. You might find that hanging out with certain people causes you to use. Are you hanging out with them because you are bored and don’t know what to do?

Boredom is a good sign. I love it when patients tell me they are bored. Boredom means you are getting better. In the past, you may have spent your time waking up in withdrawal, only able to think about where you will get money for buying drugs. It takes a lot of time to buy the drugs, as well as being high. Being addicted to opiates is a lot of work, and it takes up a lot of time. When you are getting better, you may find that you have a lot of extra time on your hands.

One way to deal with boredom is to explore a hobby. Maybe you used to like to do some art or play a musical instrument, but gave it up when you started using drugs. You have likely forgotten how much you like to do these things. Art and music are great for relaxing and feeling creative. If you have never tried art or music, now is a good time to try. Go into an art store or a used musical instrument store and see what is available. It is fun, and can be a life long source of enjoyment. It is also a great way to express yourself.

Exercise is a great way to fill those boring moments. It is also very good for feeling healthy. You don’t have to dive right into boxing, skiing, or cycling, but you can work up to it. Walking a block, then jogging a block, and so on, is a great way to start. Don’t push yourself too hard at first. You want to set a pattern for yourself, and so you don’t want to overdo it at first. In the winter, skating and just walking in the snow are more fun than you may think. Give it a try.

Hanging out with friends is also a great way to deal with boredom, but be selective about which friends you hang with, because being with certain people may lead to relapse. Maybe you had friends that did not use drugs, that you stopped seeing when you starting using drugs. Those are the friends you could go back to. They will likely be more forgiving than you can even imagine. Family that you trust and like, can be the helpful as well.  Some family may not. Again, be selective.

One of the best ways out of boredom is work. Working makes you feel better about yourself. You feel productive. You feel like you deserve, and need, a rest, so the down time is relaxing rather than boring.

If you have been out of work for a while, you may feel unprepared to go back to work. You may even feel scared to work. You may feel that a full time job will be too much to handle. A good way to ease back into work is to volunteering. That way you are free to leave if it doesn’t work out. You can also work as many or as few hours as you like. Volunteering also helps you feel good about yourself, because most cases of volunteering involves helping people. Then, when you are satisfied that you can return to work, you can take on a part time job, and gradually increase your hours to where you feel comfortable.

There are many volunteering organizations that are usually looking for people to help out. Pick something you like and believe it. Here are some suggestions, but there are many more than these:

Local Libraries

Food Bank

Salvation Army


Habitat for Humanity – They build housing for people with low income. This is construction work mainly. Many people start there, and meet people and end up with a real job in the end.

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Do You Need Photo ID?

Some patients find themselves without any form of photo identification (ID), for various reasons. Maybe you lost your wallet, were robbed, or ended up in jail and never had your ID returned to you when you were released. In any case, Photo ID is essential in our society. Maybe you are managing without it right now, but eventually you will need it.

Getting an OHIP card, or renewing an old one, requires valid government issued non expired photo ID. Without this photo ID, you can’t get OHIP. That means no doctor’s visits (without paying cash), no preventive medicine visits to the family doctor, and difficulty should an emergency arise.
Please keep in mind that if you have the old ‘Red OHIP card,’ you will have to get a new one. In the past these cards ‘never expired,’ but due to abuse of the system, the government has been calling them back, and forcing you to get a new OHIP card. You will need ID to get a new one.
Photo ID is also required for various other things as well. This includes getting a driver’s license, passport, bank account, and many other things that you need. Part of your recovery is getting your ID straightened out.
Here are some suggestions to getting your ID:
1) Ontario Photo Card 
You can apply at any Ontario Service center.  It costs $35.  You will need a photo.  You will also need some original documents to prove your legal name, date of birth, and signature.  The requirements, and a list of acceptable documents, are available online.
2) Try getting an Age of Majority Card from the LCBO
They require some ID to get the photo ID, but then that photo ID can help you get other ID later on. For example, if you have a Birth Certificate and expired photo OHIP card, then you can get an Age of Majority card for $30. This may sound strange, but most places will not accept an expired passport or photo OHIP card as ID. But it can help you get a real photo ID by getting an Age of Majority card.
3) PAID Clinic – open weekdays
416.691.7407, 3036 Danforth Ave, Toronto On M4C1N2
4) Albion Neighbourhood services – ID clinic – open Thursday mornings
They can also help with employment and housing
416.741.1553, 1530 Albion Road ste 205
5) ID online –
6) Renegeration Outreach Community ID Clinic
156 Main st, Brampton
Free ID services

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Seeing your Therapist as an Ally

Your therapist is trying to help you. This therapist may be your methadone doctor, psychiatrist, family doctor, counselor, psychotherapist,etc. In any case, they are trying to help you. In order to help you, they need all the information that you can give them. If you hold back some information, they may be missing some very important things that could affect your care. It is to your benefit to have full disclosure with your therapist.

In my addiction medicine practice, one area of dishonesty is cheating on urine drug screens (UDS). If you used street drugs, and are worried about losing carries, be reassured that you only lose one carry, and get it back the following week if your UDS is does not show street drugs. However, if you get caught cheating, you lose all your carries, and cannot get a new carry for one full month. If you cheat a second time, then you lose all carries and cannot get a new carry for three months. This would also seriously erode the trust between you and your doctor. It takes a long time to regain this trust.

It is much better just to be honest, lose the carry for one week, and move on. If you think about it, cheating on your UDS can seriously compromise your own recovery.

Being honest about what drugs you are using has other benefits. A major component of addiction is dishonesty to yourself. If you lie to your therapist, you can more easily lie to yourself. Not lying to your therapist will help you not lie to yourself.

Another benefit of honesty is showing your therapist your commitment to getting better. I have seen many patients come in and tell me “my UDS screen is faulty because it is showing that I did not use, but I did.” They know full well that they will lose a carry by telling me this, even though the UDS is negative. When I mention this, the reply I usually get is “I know, but I really want to get better.” This speaks volumes. You lose a carry for using drugs for your benefit alone. It is very important that you understand this.

Your therapist is your ally. Be honest, tell them all the street drugs that you use – even if they don’t ask you – and don’t hold back. Only then can your therapist fully help you. Your therapist wants to help you.

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Quitting Smoking

Although studies have shown that relapse rates for smoking are higher than for any other drug, the following can help you with trying to quit.  The good news is that the physical addiction to nicotine only lasts for about three days. After that it’s all psychological, and mostly habit.

The first step is deciding that you want to cut down, or even stop, smoking. Then choose a date for when you want to quit, but make it one or two months in the future. Don’t try to quit tomorrow or the next day. Many people find quitting on a Monday works best. Tell everybody you know that you are going to quit on your quitting day. Ask them not to offer you a cigarette after that day.

Take a week and write down every time you have a cigarette. Write down the reason why you are having a cigarette. It may be because it’s first thing in the morning, after a meal, with a coffee, you’re stressed, you’re happy, you’re driving, and so on.  Theses are your triggers.  Things that make you want to smoke.

Once you have a list of your triggers, order them in priority. Put the ones that are less meaningful to you at the top and the ones that are more meaningful to you at the bottom. This is the order you will be addressing your triggers.

Now try to come up with an alternative to smoking cigarettes for each of these triggers. For example, first thing in the morning, instead of having a cigarette try doing a few push-ups or situps. By the end of the exercise, you will likely not want to have a cigarette. For smoking in the car or house, make a deal with yourself that you have to go outside to smoke. If you’re on the highway, you have to pull over and get out of the car to have a cigarette. This will help keep your car and house from smelling like cigarettes, and will reduce the trigger of cigarette smell making you want to have a cigarette. After a while, you will start to dislike the smell of cigarettes.

One thing to watch out for is to not replace one habit with another. For example, replacing smoking when you’re stressed with eating chocolates can results in other problems. Try something you like to do, but that is good for you.

Once you have done this, you will likely be one or two weeks into the quitting process. Trying to eliminate the trigger at the top of the list. Once you have done that, move to the next one. By the time you get to your quitting day, you will likely be down to the last two or three triggers. These will probably be the hardest triggers to remove, but you will have had experience in removing the other triggers.

After quitting day, try to avoid people who are smoking, places where there is smoke, and things that make you think of smoking. Do this for at least a month.

If this doesn’t seem to work, talk to your doctor about some medication that can help you with the cravings. Most people do not need any such medications, but they come in handy for some people.

Good luck in your endeavour to improve your health and enjoyment of life. Things really do smell, taste, and look better once you quit smoking.

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Depression, Anxiety, and Panic Attacks

Anxiety, Depression, and Panic Attacks are common complaints of people who use street drugs. Sometimes, these problems are actually a result of street drug use. Withdrawal from opioids can cause severe anxiety and depression. Being high on cocaine can cause anxiety. Coming down off of cocaine can cause depression. Prolonged use of marijuana can cause mild chronic anxiety or depression.

If it has been several weeks since you last used any street drugs, and you still have some residual anxiety or depression, there may be something else going on. The causes of these symptoms can be many. You may now be seeing the damage the drugs have caused to your life. You may think that repairing this damage is overwhelming. This damage may be in the form of injured relationships, body parts, jobs, or any number of other things that are now important to you that were not important to you while you were using drugs. The good news is that it’s most of these things can in fact be repaired. Have hope, and ask for help. It is hard to do it alone.

Some people may have been using drugs to self medicate their anxiety and depression. If this is the case, then when the street drug addiction is treated, they are left with their underlying mental health issues that have not yet been addressed by a professional. Although the best way to treat this is to see a professional counselor, it is often difficult to find one that is free. Ask your doctor about this, and hopefully they can help you find one, or they may able to help you themselves.

Panic attacks are a sudden rush of anxiety and other feelings that lead to a “feeling of impending doom.” Commonly, people have problems breathing and focusing their attention, as well as many other symptoms such as chest pain, sweating, and many many more things. If you experience any of these symptoms, please consult the doctor first. The most important thing is to rule out something that is physically wrong. These symptoms are very similar to heart attacks and other very severe medical conditions. Once these medical conditions have been ruled out, then you are left with the diagnosis of panic attacks. At this point, you can move on to treating them through some the techniques noted below.

Often the full-blown panic attack is a result of just worrying about having a panic attack itself. When you feel a panic attack starting, you may start thinking “oh my God I’m going to have a panic attack”. You may then think about this over and over again, concentrating on the physical feelings that you are experiencing. Obviously, this will make a panic attack much worse. The best way to deal with this, is to try to keep your mind off of the panic attack and “talk yourself out of it.” Some counselors call this “riding the wave.” The idea is not to fight the panic feelings, but to accept them, let them flow through you, and concentrate on something else while you wait for the feelings to leave. Many of my patients have tried these techniques, and find that their panic attacks last 30 seconds to one minute if they use these techniques.

The basic idea, is to try to distract your attention from the panic attack onto something else. Choose ONE technique from each of the 2 categories, and work on them. If they don’t seem to be working, try another. Make sure you try it at least once a day. Give it some time, maybe a week. Don’t try too many at once, just one at a time.

1) Distraction Techniques

Exercise – Pushups, Walk, Hike, Bike

Talk to friends
Take photographs
Write a Journal, Poems, Story (some of the best creativity comes from artists at time of great emotional pain)
Play a musical instrument
Play video games
Paint your nails

Cry (this is very good at releasing internal chemicals that will make you feel better)
Throw rolled up socks, pillows, or foam balls against the wall
Scream into a pillow or a secluded place
Punching a pillow

1) Self Soothing Techniques

The second technique is to soothe yourself by using your five senses: sight, touch, smell, hearing, and taste. To find a technique that is good for you, just think about these five senses, and come up with something that you enjoy. The list below is simply a list of examples that you may find helpful.

Carry around a small bottle of perfume or other smell that you enjoy – smell it when you’re feeling bad or about to enter panic attack

A piece of fabric, leather, fur, or even an ice cube that you can rub your hand on and concentrate on the feeling

Eat – chocolate, salty foods, or whatever you find comforting (but watch your weight)
Watch TV movie
Listen to music
Singing a song you like
Have sex with someone you care about
Take a bath

Concentrate on your surroundings:
How many different sounds can you hear? How many birds?
How many different smells can you notice?
Look at the sky and/or your enviroment around you and see how many shapes, textures, and colors you can identify

I hope you find these helpful. Please keep in mind that this is just the beginning. A counselor can help you identify what will help you specifically. They also may have other ideas that can help your case in particular. Good luck, and remember the idea is to enjoy yourself.

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Trouble Sleeping?

Many people have problems with sleeping. There are many things you can do to help this situation.

If you are having trouble with sleep, the first question you must ask yourself is ‘am I taking any stimulants?’ Stimulants include caffeine (in coffee, tea, Red Bull, and many other things like Tylenol 1), diet pills, some cough and cold remedies, cocaine, amphetamines, ecstasy, LSD, and many more. Stimulants can keep you from getting to sleep. Try cutting those out. Your sleep would likely improve within a few days.

When you are using opiates, benzos, alcohol, or other sedating drugs, sleep is easy. The problem is that your body gets used to the dose after a while, and you need more to have the same effect. The other problem is that if you take too much, the sleep can become permanent – you can die. After a while of going to sleep with the help of drugs, you may start forget that going to sleep is a process that you worked on since you were a little child. When people stop using drugs, they often need to relearn how to go to sleep.

If your mind is active, it is harder to sleep. That is why, for most people, activities like watching TV, playing video games, or just being on the computer right before sleep can keep you from sleeping. Try something more relaxing for you, like reading a book. If you find the book boring, even better. You would likely drift off quite quickly. Give yourself a good 20 minutes of reading before you give up.

Exercising right before sleep can also keep you awake. The increased blood flow and adrenaline will keep you up for some time. On the other hand, being physically tired can help you get to sleep. It can help soothe any anxiety you may be having. So, exercising an hour or more before sleep is actually best.

You may have trouble with sleep when your mind runs around in circles, thinking of things you have to do or that are bothering you. In this case, meditation or relaxation techniques can help greatly. Try some of the MP3s that are on this website on the right hand column. They are instructions, not just music or sounds, that can help you relax and focus your mind on becoming calm and clear. Other websites have these types of instructions as well, so search around. If you don’t like one, just move on to another until you find the one you like.

If you have honestly tried all these things, and are still having difficulty, please talk to your doctor. They can prescribe medications that are safe for you. You may need to do some lab work before starting the medication, as some medications can cause trouble with your liver or other organs. Many sedating drugs (i.e., drugs that make you tired) suppress the breathing centre in the brain. So does Methadone. If you add them together, you can stop breathing in your sleep. In fact, the most common way for people to die on Methadone is from also taking alcohol and/or benzodiazepines. So, taking these medications under medical supervision is the safest way.

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Cannabis in Pregnancy (and in general)

Some interesting research has come up recently regarding cannabis and pregnancy.  Although cannabis is  considered a ‘soft drug’, as opposed to things like heroin or cocaine, it does have problems of its own. Weight gain, poor memory, and breathing issues are among the main concerns.

With the legalization of cannabis in Canada, it is now regulated.  That means that Health Canada reviews the products to make sure they do not have other drugs in it, and are produced in a safe way.  Street dealers can, and do, put all kinds of drugs into cannabis.  I have even read about formaldehyde being use.  This is a poison.  Unfortunately, it can give a high similar to cannabis, so dealers sometimes put it in if the cannabis is not sufficiently strong for their customers.  In my clinic, I have seen that street dealers have laced cannabis with fentanyl, among other drugs.  I have also found that cannabis frequently has traces of cocaine or benzos in it.  This may be intentional lacing from the dealers, but it can also be from cutting the various drugs on the same table, or using the same uncleaned scales for all the drugs they sell.  In any case, a lot of the street cannabis is not safe.  Please use the Ontario Cannabis Store (OCS) if you want to smoke cannabis.

Cannabis has also been shown to cause an increased risk of developing schizophrenia in youth who are predisposed to developing it.  Unfortunately it is hard to predict who is predisposed.  That means that a youth who uses cannabis may develop schizophrenia only if they use it, and not otherwise.  This is quite serious.  It is often not reversible.

Recent research is showing that cannabis has further issues if taken during pregnancy.  There is evidence arising that cannabis taken in pregnancy can have irreversible negative effects on the fetal brain.

Of course, all of the concerns that I mentioned above apply to pregnancy as well.  That means formaldehyde or fentanyl in your cannabis may be getting to your fetus, which can have further effects on your child.

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Methadone and Codeine

Over-the-counter (OTC) medications are medications that you can buy from a pharmacist without a prescription. Patients often complain that OTC drugs should not be restricted in the Opiate Replacement Therapy program because they are available without a prescription. I will discuss the reasons you should not use OTCs drugs that contain Codeine.

Codeine is a common ingredient in OTC drugs. Please check the ingredients on your OTC medication to see if Codeine is, in fact, present. Examples of OTC medications that contain Codeine include Tylenol 1, some cough syrups, Robaxacet, as well as various allergy and cold remedies.

Even a small amount of Codeine can cause your urine drug test to become positive for Morphine. This is because Codeine is metabolized by the liver into Morphine. In fact, Codeine itself has no pain relieving action on the body. This is why people do not inject Codeine. Codeine must be eaten, and then it will pass through the liver, get metabolized into Morphine. Only then can it give it’s pain relieving qualities. So, in the end, if you take even a small amount of Codeine, your urine drug test results will look the same as if you were using Heroin.

For this reason, it is important that you avoid all Codeine containing products while in treatment.

Pain is a very useful thing. It lets you know that you have caused damage to your body. It is not always to your benefit to remove all, or sometimes even any, of the pain. The pain can help you avoid certain activities that are causing your body harm.  Also, any opiate medication that you take will mask the pain, and may result in delayed diagnosis and appropriate treatment of the cause of the pain.

For example, you may have back pain from working. If you take Codeine, the pain will be reduced, and this will allow you to work more. But the cause of the pain has not been treated. So, continuing to do what caused the pain in the first place will make the pain, and damage, worse. The result will likely be more pain. In general, it is important to avoid using Codeine unless advised by a doctor.

If you are using eight or more Advil or Tylenols per day, then you should see a medical professional. Both of these medications have side effects, so prolonged regular use can result in damage to your body. Sometimes this damage can be permanent and potentially life-threatening.

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