CONTROVERSIES IN PSYCHIATRY
Summer 2021 Issue |
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Controversies in Psychiatry
Controversy of Cocaine Detox
By Benny Pierce, MD
LewisGale Medical Center
Joseph Knoble, MD
LewisGale Medical Center
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| Dr. Pierce |
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| Dr. Knoble |
As substance abuse treatment has evolved over the last few decades, an underlying framework has emerged between hospitals, mental health professionals, and outpatient treatment programs. Historically, this approach benefited those with severe alcohol or benzodiazepine addiction, as these often required hospitalization due to the severity of their withdrawal complications. But as opioids have escalated in potency, the likelihood of hospitalization has increased in turn. This hospitalization paves the way to the network outlined above, facilitating the step down transition to outpatient programming. Similarly, amphetamine intoxication resulting in psychosis, a not so uncommon phenomenon that occurs in up to 40% of chronic users.
Unfortunately, those who abuse cocaine have historically been left out of this paradigm. While cocaine often results in psychotic episodes, these are generally described as short lived and transient. Furthermore, the absence of life-threatening withdrawal symptoms leads to very few cocaine specific admissions to public or private hospitals outside of the Veteran’s Affairs. At first glance, the National Institute of Drug Abuse points to the significantly higher mortality (~50,000 deaths/yr) linked to opioid use; however, this minimizes both the cardiovascular morbidity and socio-economic impact that cocaine certainly entails. Cocaine dependency, like other drugs of despair, is the byproduct of a complex interplay of social, economic and political factors but must not be lost in the shuffle.
It is particularly troubling to consider that the disparity in the healthcare system’s approach to cocaine use may be rooted in prejudiced policies during “The War on Drugs”, aimed at African American and other lower income communities. Although the discrepancy in legal ramifications between crack versus powder cocaine use has gradually been recognized, starting with the Fair Sentencing Act of 2010. Yet, this is only the tip of the iceberg. As topics of mental health and addiction move further and further under the limelight since the start of the pandemic, psychiatrists must warm up their vocal cords as the demand for community, regional and national leadership intensifies. We challenge trainees and independent practitioners alike to look at existing trends in treatment approaches and ask “Why?”
While issues like these are identified and considered, a fundamental part of the solution likely involves another area rooted in historical trends; psychiatric residency training. While our patient population has dramatically transformed throughout the last 50 years, one should question if residency programing has made the requisite adaptions, beyond applying the most up to date DSM criteria. Creating initiatives to diversify recruitment as well as educational experiences may aid the field of psychiatry in rising to this task.
At our hospital, the newly formed Diversity, Equity and Inclusion Committee is working to re-invigorate direct ties between education and the community in which we serve. Although the impact of a poorly representative body of psychiatrists cannot be quantified, one must wonder what approaches or ideas that may be missing from a workforce where less than 1 in 50 are black or latinx and only about one in three are women.
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