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.