If you take ice, avoid our emergency departments

Greetings all,

I write today about a topic I have become familiar with, after working as a locum psychiatrist in Far North Queensland. In no way do I think FNQ has problems that aren’t seen elsewhere, far from it, but it was my chance to see first hand what the drug ‘ice’ was doing to our society.

I work as a psychiatrist and hence within the public mental health system which to say is under resourced is old news. We are way past under resourced now and as clinicians move from crisis to crisis providing band aid solutions to complex psychiatric solutions all the time. I accept that fact and like many of us, aim to do my best with what I have. But I will not abide by the recent influx of demand that has occurred as a result of the increasing use of ice. I do this to support my colleagues as as well as patients being cared for in the mental health system.

Ice is one of the most powerful, addictive and dangerous substances that our society has known. A ‘bad trip’ on ice is not the same as an experience with heroin or other psychostimulants. Because methamphetamines, including ice, affect levels of dopamine in the brain, they will cause patients to become psychotic merely because of their ingestion. In other words, if you take ice, you have a very high chance of becoming paranoid, misinterpreting things around you, including within your own body (commonly feeling there are objects or insects under your skin) and you may very likely become more violent than ever imagined as a result.

Someone who is acutely intoxicated because they have used ice is not the same as somebody who is experiencing symptoms of severe mental illness that requires immediate treatment in an authorised mental health service. Patients who are intoxicated on ice will often be fine once the substance leaves their system. They don’t need to be labelled with a diagnosis of a severe mental illness, and as such take up hospital beds and terrify other patients who are in the wards for other reasons.

Yes, we do know that there is an overlap between the use of illicit drugs and psychosis with the use of drugs precipitating a psychotic episode in a person who is genetically vulnerable. But what we are seeing in many cases is acute intoxication of a substance that we know causes psychosis and these patients are being labelled as having a severe mental illness simply because we need them out of our emergency departments due to bed targets within a period of time. In a system where medical and nursing teams are expected to triage, assess and admit every patient in an emergency department within a designated time period, we have lost the ability to use time as a healer.

When I was a psychiatry registrar I was routinely asked to assess patients who were intoxicated with alcohol and expressing thoughts of suicide. I knew that for clinical, ethical and medico legal reasons, I could not assess the patient until they were sober. In the cold light of day, and once alcohol is excreted from the system, a patient may no longer pose the same level of risk. It is the same for ice. During my recent locum post I was disappointed and shocked to hear that psychiatry registrars were routinely called to the emergency departments to see patients who were ice users, intoxicated and violent as a result. When ice dried up in town, the request was to see people who had obtained the medication ‘Ritalin’, crushed up the tablets and injected that instead. When ice dried up, users would collect at the community clinics threatening staff and demanding prescriptions for Ritalin.

I know that some ice users do have an underlying psychosis and as such deserve a different model of care. It is a tragedy that patients with severe mental illness now have access to ice with disastrous consequences on the prognosis and course of their illness. But I don’t feel we should assess which camp the person belongs in before they ‘come down’, and we shouldn’t sedate them with heavy doses of antipsychotic medication which may cause breathing difficulties and lengthen the time in hospital.

I don’t feel we should admit ice users to a psychiatric ward, with other vulnerable patients and staff, without a very valid reason. Because I know that if given time to come down, many would not require any treatment at all.

In FNQ there exists diversionary centres, created as an alternative place for those intoxicated with alcohol that is not part of the forensic or medical system. Diversionary centres are seen as safe places to withdraw from alcohol, avoiding custody. Now that we are at crisis levels with the numbers of ice users increasing beyond our level of understanding or capacity to respond, a similar model could be employed. Such a model would provide a safe place for users to withdraw, away from clinical staff and other patients, and then a comprehensive mental health assessment could occur when the risk of violence had dissipated. We need to curb the tidal wave of admissions to psychiatric units by ice users, for the sake of our profession, our patients and our colleagues.

Coaching and training in preparation for the RANZCP M-OCIs

It has been a busy time helping IMG candidates with their exam preparation ahead of the next 2 weeks! As their current training pathway comes to an end (October 2015) I know many are keen to do everything they can to prepare for the long case exams.

As a trainer, I often see the same thing happening with candidates, and as such I thought I would jot down some key points as well as provide you with some written material about how best to approach the exam. I am available for individualised coaching, and booking up ahead of the July and October 2015 RANZCP clinical examinations.

  • Being ‘nice’ rather than asking direct questions or drilling down into the information you need. I see this time and time again. Being nice does not equate to missing out on key information, that if known would help the patient in the end. If a patient appears guarded and defensive it is probably a useful clinical sign to notice, rather than taking it personally.
  • Focusing on the formulation and running out of time to prepare an action plan. The action plan is marked in a separate domain, formulation isn’t, and many candidates fail as their plan is not well considered or specific as they have left it to the last few minutes to prepare. Remember to weave the demographic details into the action plan to make it specific.
  • Pay attention to cues, and ask patients to tell their story so you can observe their narrative and non verbal communication that goes with it. By doing this we are truly dong what good psychiatrists do, synthesising all the information available to us, and allowing the patient to be truly heard.

Here are some other tips, please share!