Substance Use Knowledge Amongst Emergency Room and General Medical Personnel

Recently I had the misfortune of having to receive emergency treatment for a heart attack. I used this opportunity to do some investigation into how much emergency and other medical personnel know about substance use, and how much training they have been given.

Before I go any further, I would like to state that all the staff that I interacted with were excellent, and I believe I received a high standard of care, so I am not looking to criticise them or their abilities, but rather spot gaps in their training, pertaining specifically to substance use.

Let me explain the setting: I live in Cape Town, South Africa. Medically speaking, we have some excellent medical schools here, specifically the University of Stellenbosch and the University of Cape Town. Medical students have a particular advantage in the South African medical schools in that they receive first world training and third world experience, meaning that by the time they qualify they have usually seen pretty much everything first hand. The public health sector, where I received my treatment, is generally good, but overburdened.

From a substance use point of view we have a large portion of the population who are economically disadvantaged, and, as a legacy of apartheid, we have townships where the previously disenfranchised were forced to live. This has led to a gang culture, and this economy is fuelled by, amongst other things, the drug trade. The main drug of choice for those seeking treatment in the Cape Town area is methamphetamine (33%), but those seeking treatment for heroin use has risen to 15% recently, and heroin is fast becoming the come-down drug of choice, and because of the rapid rate of dependence that users experience, will become a much bigger problem in the future. Most of these substances are of high quality, and are smoked, although we are seeing increasing numbers of IV users.

In the ambulance I was able to talk to the paramedics. Did they come across a lot of overdoses? Yes, but these were mainly suicide attempts. When I asked them if they had seen any heroin overdoses, they said yes, but had not received any formal training on how to deal with these or any other illicit drug overdoses. They did not carry Naloxone in the ambulance, and were not aware of its role in the prevention of opioid overdose. When I asked about psychosis, they said that this was one of the more common things they saw, but usually it was left to the police rather than the ambulance service to collect these patients due to the violent response that was often encountered.

At the emergency room I had the opportunity of speaking to a number of the doctors about substance related issues. By far the most common consequence of drug use they had to deal with was Substance Induced Psychosis, either as the result of Methamphetamine use or related to the use of high grade cannabis. These patients were stabalised and referred to the psychiatric ward for 72-hour observation. Most of those with a substance induced psychosis would be absent of the psychotic symptoms at the end of the observation period and would be discharged. What I found interesting was that there was no screening for substance use and no referral process. The emergency staff would only suspect that illicit substance use was involved if the family informed them or if the patient became a revolving door patient.  

Most of the doctors had little understanding of substance use, and there seemed to be a level of prejudice against substance users. One of the doctors said “these addicts are just wasting our time. They should just stop”.  She was also responsible for taking my medical history and it was a bit awkward when I informed her that I had been a methamphetamine user for nearly a decade! We did have the opportunity to chat for a while, and hopefully I was able to explain a few things about addiction to her. In spite of this doctor’s lack of knowledge about substance use, it was still better than the doctor who asked if cocaine was the same as heroin. Both of these doctors had only had a couple of lectures dedicated to addictive disorders in 6 years of training.

The nurses had had a lot more direct experience with substance users, but then many of them came from communities where substance use and gangsterism was common. Many of them were more adept at spotting substance users, but also seemed to have a more judgemental attitude. Many of them said that if a psychotic patient came in on a weekend shift they presumed it was due to drug use, and they would just wait for the drugs to wear off.

On the other end of the scale the emergency room cardiologist I saw certainly wasn’t judgemental at all, but did highlight another problem. She was looking at my file and calmly suggested that if I was concerned about not having another heart attack it would perhaps be a good idea to consider stopping my methamphetamine use! Didn’t raise an eyebrow or have a hint of condescension in her voice! Since this was an academic hospital she was accompanied by a group of medical students, some of whom seemed a little unsure of her casual approach.   I was quick to point out that my substance use disorder had been in remission for a number of years. The problem this highlighted was that the doctors have little idea of how to record substance use disorders in the medical history of a patient. 

After 18 hours in emergency I was transferred to the medical ward which was adjacent to the psychiatric ward. I was able to speak with many of the nurses about their experiences with substance users. None of them had had any specialised training in substance use disorders. Many of them seemed exasperated by the behaviour of substance users: Continued use in the ward toilets in spite of serious medical conditions, repeated visits to the psych ward due to substance induced psychosis.

After I was discharged I had the opportunity of speaking with the head psychiatrist and the social worker at the hospital. Both were aware of the stigma attached to addictive disorders, and felt that there was discrimination. The social worker particularly acknowledged that amongst medical staff there was the feeling that substance users and suicide survivors were wasting resources because they had brought things upon themselves. When a patient did happen to be identified as having a substance use disorder, usually by family members, they were referred to the social worker. The major problem as expressed by both the psychiatrist and social worker was the lack of appropriate services to refer those with substance use disorders to. Even if the patient was admitted to services there was little long-term follow-up. 

In essence, there seems to be little knowledge about substance use disorders amongst general medical staff. Training is at best limited. This, I believe, is a sad state of affairs because the emergency room often an ideal opportunity for brief intervention and referral.