Several years ago, I was in the emergency department (ED) with a loved one -- a young woman seeking treatment for opiate withdrawals and a mental health crisis. We had driven 4 hours to this particular hospital because it was a full-service medical center and included a mental health ward with a med/chem (mental illness with chemical dependency) unit. In the ED, she had become very quiet and withdrawn, not her typical behavior. When the medical doctor examined her, he kept saying the mental health unit was "very busy," and he would order her a prescription and we could follow up with someone the next day. I kept insisting we would wait -- we needed to speak with someone from the behavioral health unit. It was a desperate situation. To my dismay, she was discharged with a prescription for clonidine (Catapres tablets) and advice to find help elsewhere. She left my house the next day and returned to the same situation we were attempting to remedy. She lost hope.
She attempted suicide 2 weeks later. She took the full prescription of clonidine and almost succeeded in ending her life. During the ensuing 5 days of hospitalization she decided to get help. She was discharged again, and this time was willing to enter treatment. She is now living with 5 years of recovery.
But we almost lost her. The doctor in the ED never asked for a consult with the in-house addiction specialist or the mental health unit we were requesting. The mental health unit was not at fault. They were never called, and they did not provide the discharge.
As a pharmacist, a family member, and a person living in recovery from addiction, I have seen both the good and the bad when it comes to treatment in a hospital setting. The stigma that results from years of experience and gossip affect the way you see the patients in crisis from mental illness and substance use disorders (SUDs). This prevents you from seeing the patient. If a condition that brought them to the ED was caused by drug use or mental illness, and that initial cause is not treated, that patient will return -- often with even more severe symptoms or worse. Those who have sought treatment services know we often find ourselves in medical facilitates at times of crisis. This is when we have a window of opportunity, a desire to change, or simply a desire to live. This is when you, as a medical provider, can be the lifesaving catalyst for us to enter a life of recovery.
These are my questions and concerns:
ED Protocols for Withdrawal Symptoms of SUD
What is your ED's protocol for a person in crisis requesting assistance with opioid withdrawal?
- Is addiction medicine (i.e., buprenorphine, chloral hydrate, etc.) administered? Do you have an addiction specialist team?
- Do you then provide a prescription for enough medication until the scheduled appointment with an outpatient treatment program can be secured?
- Is this outpatient appointment scheduled before the patient leaves the hospital?
- Is a person experiencing withdrawal from alcohol, benzodiazepine, or multiple drugs admitted for an inpatient medically supported withdrawal (DETOX)?
- Do you enlist the support of local peer professionals and make referrals to recovery centers or other supports?
Overdose Protocols
What is your ED's protocol for a person who has overdosed?
- Is a patient who is lucky enough to be found in time and transported to the hospital after a life-threatening overdose admitted?
- Are they admitted for 72 hours and provided inpatient medically supported withdrawal while further treatment is located?
- Is a "danger-to-self" recognized, as the patient has been triggered in severe withdrawal and likely to reuse immediately upon leaving?
Mental Illness Crisis
What is your ED's protocol for a person having a mental health crisis?
- Is a person presenting for a mental illness crisis first stabilized and medicated until they reach a lucid state before discharge?
- Is a contact or loved one (or peer advocate) reached for information?
- Is the behavioral health unit of your facility contacted to make the determination to admit or discharge this patient?
- Is "danger-to-self" required for treatment, and does drug use negate this requirement? Note that drug use may be a symptom not a cause, and this determination cannot be fully addressed until the patient is in a lucid state.
For most cases of willing patients in crisis, whether or not any of the above happen depends on which provider sees the patient. In most instances it has traditionally been a case of "treat and street." This needs to change.
This epidemic is bigger than the addiction treatment and recovery community can handle on its own. Many people in crisis have been so close to opportunities that could lead them to recovery, only to be turned away. Guidelines for this care were recently published in the Annals of Emergency Medicine on June 23.
We -- patients of mental illness and SUDs -- are told to simply ask for help but then told there is a waitlist of 1 to 3 weeks. When a patient is willing, the iron is hot! This is when we need the medical community to strike quickly. You have the power to change the direction of this epidemic.
Sue E. Martin, RPh, is a pharmacist, a person in long-term recovery, and an advocate for access to treatment with Recovery Advocates in Saratoga (RAIS).