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Re: Psychoactive substance misuse in emergency medical care: lessons from psychiatry

Dear Editor,

We note with interest findings by Binks et al.[1] that almost 50% of emergency department presenters with direct consequences of “illegal drug” (psychoactive substance) misuse had a psychiatric disorder or emotional difficulties associated with deliberate self-harm.

Our experience in emergency psychiatry on a Psychiatric Intensive Care Unit (PICU) also identifies very high rates of substance misuse, (90-100%) among a cross section of presenters. Cannabis, crack, cocaine and amphetamines are the main drugs used. Individual or combined use of these substances is associated with wide variations in clinical presentation. This may be further complicated by use of “legal” substances, e.g. alcohol and mood altering prescribed medication (opioid analgesics and steroids). The patterns, quantity and aftermath of substance use invariably influence clinical interventions such as the need for admission and duration of hospitalization.[2,3]

An awareness of the stage in the career of substance misuse e.g. intoxication, dependence or withdrawal can inform emergency and post-emergency management. In such situations multidisciplinary interventions with Crisis Intervention, Psychiatric Liaison, or Addictions services may prove invaluable. The “revolving door” patient with unresolved crises can significantly impact on sparse resources and is best identified for more detailed assessment and intervention.[2,3] Some of these individuals also experience severe personality difficulties that may be emotionally challenging to staff.

Awareness of the relationship between substance misuse and its clinical consequences has public health implications as secondary psychiatric sequelae such as organic brain injury, drug-induced psychosis, mood disorders or schizophrenia may ensue. Furthermore, serious assaults or injury may lead to the development of posttraumatic stress disorder.

Extrapolating the findings that large numbers of emergency admissions are related to substance misuse, the clinical risk and resource implications are vast with significantly increased morbidity and mortality. As substance misuse is often associated with criminal behaviour, social, psychiatric and medical consequences, emergency presentations offer critical opportunities for multiagency interventions.[3]

References

1. Binks S, Hoskins R, Salmon D, Benger J. Prevalence and healthcare burden of illegal drug use among emergency department patients. Emergency Medicine Journal 2005;22:872-873.

2. Zahl DL, Hawton K. Repetition of deliberate self-harm and subsequent suicide risk: long-term follow up study of 11 583 patients. British Journal of Psychiatry 2004; 185:70-75.