When written in Chinese, the word ‘crisis’ is composed of two characters. One represents danger, and the other represents opportunity.1
Mrs. R, age 43, is agitated and confused, and her husband has brought her to the hospital’s emergency department. He reports that she has a history of denying alcohol abuse and told him during an argument yesterday that she could stop drinking any time she wanted to.
You are the psychiatrist on call. As the emergency medical team treats the apparent withdrawal episode, you tell Mrs. R’s husband: “We’ll take good care of your wife because alcohol withdrawal is dangerous and painful. But after detoxification, it’s important to prevent her from getting sick again. She needs to enter a rehabilitation program, and then outpatient treatment. When she comes around, maybe you could remind her about how much pain she was in and bring her to the rehab center yourself…”
Addicts face potentially life-threatening consequences from their behavior, which—when handled skillfully in the emergency room—can start them on the road to recovery. Some say the addict must “hit bottom” before making the changes necessary for a sober life. You can help the addict define his or her bottom as an unpleasant trip to the hospital—instead of death or loss of a job or spouse—by realistically assessing the physical consequences of continued drug or alcohol use (Table 1).
ADDICTION EMERGENCIES: HOW DEADLY?
Emergencies related to alcohol or drug use accounted for 601,563 visits to U.S. emergency departments in 2000, according to the government-sponsored Drug Abuse Warning Network (DAWN).2 Alcohol in combination with any illegal or illicit drug accounted for 34% of emergency visits, cocaine for 29%, and heroin for 16%.
Mortality rates vary by region. In Los Angeles, for instance, heroin and cocaine each caused approximately the same number of deaths when compared with alcohol in combination (Figure).3 Most deaths (73%) were considered accidental/unexpected, with 19% coded as suicide. New York City showed similar percentages of deaths called accidental/unexpected, but heroin as the cause of death ran a distant fourth to cocaine alone, narcotic analgesics alone, and alcohol in combination.2
Addiction crises bring more than a half-million Americans to hospital emergency rooms each year (Box 1,Figure).2,3 This article describes teachable moments—suicide attempts, accidental overdose, intoxication, and withdrawal—that you can use to bundle acute treatment with referral for addiction treatment.
Suicide
Suicide is the addict’s most immediate life-threatening emergency. Psychiatric and addictive disorders often coexist,4 but some substances can trigger suicidal behavior even in the absence of another diagnosable psychiatric disorder. The addicted person who jumps off a roof, believing he can fly, may think perfectly clearly when not using crack cocaine.
Addiction to any substance greatly increases the risk for suicide. An alcohol-dependent person is 32 times more likely to commit suicide than the nonaddicted individual.5 And the suicidal addict often has the means to end his life when he feels most suicidal.
Figure DRUG-RELATED DEATHS IN LOS ANGELES, 20022
Diagnosing and treating suicidality require a high degree of vigilance for subtle clues of suicidal behavior. Because suicide risk has no pathognomonic signs, clinical judgment is required. Though addiction itself can be viewed as a slow form of suicide,6 signs that suggest an immediate threat to life include:
- the addict’s assertion that he intends to kill himself
- serious comorbid mental illness (psychosis, depression)7
- prior suicide attempts
- hopelessness.8
Some addicts feign suicidal thoughts or use them as a cry for help. Any mention or hint regarding suicide marks a severely disturbed patient who needs a complete psychiatric evaluation. This includes a formal mental status examination and exploring whether the patient has access to lethal means.
We cannot consistently predict our patients’ behavior, but a careful examination often reveals the seriousness of a suicidal threat, method, and intention, as well as support systems for keeping the patient safe. Consulting with a colleague can offer a “fresh look,” allowing two clinicians to balance the need for treatment against concerns such as bed availability and possible malingering.
Table 1
EMERGENCY AND LONG-TERM MEDICAL CONSEQUENCES OF ADDICTION
| Addictive substance | Intoxication symptoms | Withdrawal symptoms | Longer-term problems |
|---|---|---|---|
| Alcohol | Slowed respiration, impaired thinking and coordination, coma, death | Seizures, death | Dementia, liver damage |
| Barbiturates | Slowed respiration, impaired thinking and coordination, coma, death | Seizures | Rebound pain, hepatotoxicity |
| Benzodiazepines | Slowed respiration, impaired thinking and coordination | Seizures | |
| Hallucinogens | Paranoia, impaired thinking and coordination | Amotivational syndrome; possession is grounds for arrest | |
| MDMA(‘ecstasy’) | Impaired thinking and coordination, stroke, hyperthymia, dehydration, death | Cognitive impairment; possession is grounds for arrest | |
| Nicotine | Tachycardia, arrhythmia | Lung cancer, chronic-obstructive pulmonary disease | |
| Opiates | Slowed respiration, impaired thinking and coordination, coma, death | Skin infections, HIV, hepatitis (if injected); possession is grounds for arrest | |
| Phencyclidine (PCP, ‘angel dust’) | Impaired thinking and coordination, violent behavior | Possession is grounds for arrest | |
| Stimulants | Impaired thinking and coordination, myocardial infarction, stroke | Nasal damage (if snorted); skin infections, HIV, hepatitis (if injected); possession is grounds for arrest | |
| Inhalants | Impaired thinking and coordination, headache, coma | Neurologic damage |