Vancouver’s compassionate, collaborative approach cut ED meth user readmissions by half

Dec. 14, 2020

By Dr. Bill MacEwan, Medical Lead for Vancouver’s Downtown Community Court psychiatric teams; Clinical Professor in the Department of Psychiatry at UBC

Horizon is fortunate to have Dr. MacEwan guest blog for our readers. Learning from others’ experiences and successes helps make the health care world successful.

Methamphetamine abuse causes many challenges to our health systems, law enforcement agencies and community programs such as libraries, drop-in centres and shelters.

People intoxicated on methamphetamine can exhibit unpredictable and often violent behaviour that can cause damage to property and harm to people in the community. Psychosis can be seen in up to 40 per cent of methamphetamine users, especially those who have been on a “run” of using multiple times both day and night.

Commonly, agitated psychotic patients who are intoxicated on methamphetamine end up being apprehended by police and taken to their local hospital for assessment and treatment in the emergency department (ED).

The challenges of assessing people on methamphetamine in EDs are numerous. They include a proper assessment of whether this is a drug-induced psychosis or a pre-existing psychosis such as schizophrenia. This decision of what is the underlying cause of the person’s psychotic state will significantly influence what choices are made regarding current treatment and ongoing follow-up.

Substance-induced psychosis (SIP) is often not acknowledged by many emergency department physicians and psychiatrists. Patients with SIP are often not seen as having a problem needing ongoing treatment so are quickly discharged after their agitation is settled.

The belief is that only methamphetamine is the problem and it is not recognized that there may be an underlying psychiatric problem as well. In 25 per cent of SIP patients there is an underlying schizophrenia type of illness which needs treatment. If treatment is not tried, over time 35 per cent of people who have SIP due to methamphetamine will convert into a schizophrenia spectrum disorder.

This complex set of difficulties with a person who is abusing methamphetamine requires a broad approach that addresses the problem from many different angles.

In Vancouver during 2013-15, we experienced a huge methamphetamine crisis. This overwhelmed our emergency departments and individuals who would normally be using our drop-in centres and staying in shelters were banned due to violence and agitation. This degree of violence creates significant problems in the community often leading to many arrests for minor crimes.

There needed to be collaboration of community partners to be able to provide successful treatment for people suffering from methamphetamine abuse, addiction and psychosis.

Leadership is key at all levels of the community response for this to be successful.

The approach we took in Vancouver was led by the Vancouver City Council who in partnership with Vancouver Coastal Health and the Vancouver Police Department declared a mental health emergency due to methamphetamine abuse.

This civic coalition provided the needed leadership to allow a focus on these problems. Mental health forums and planning with representation from health authorities, police, indigenous groups, programs such as the provincial housing authority (BC Housing) and justice (the Downtown Community Court which is a justice program focussed on mental health and addiction treatment diversion).

 Stemming from the collaboration was the development of the HUB at St. Paul’s Hospital. The HUB provided increased capacity in the downtown ED at St. Paul’s Hospital, where the vast majority of people suffering from the problems of methamphetamine were being seen.

The aim was to better assess, treat and follow-up individuals suffering with addiction and psychosis from methamphetamine.

The other component was short term transitional housing program (2-3 days) modelled on the Rotary Center at St. Michael’s Hospital in Toronto. The St. Michael’s transitional housing program has been very successful in bridging people from the ED into the community and dropped readmissions to ED within a month from 70 per cent to 30 per cent.

Funding for the HUB came from the non-profit foundation Street to Home, City of Vancouver, the Vancouver Police Foundation, private donations and Vancouver Coastal Health.

These approaches allowed actions to be implemented by all of our collaborators. This continued to strengthen the partnerships between these agencies and to collectively gather and analyze the results of our plans and programs.

To pretend we conquered the methamphetamine crisis would be naïve. Street drugs and their effects on our most vulnerable people continue in Vancouver. The approach we developed with our collaborators has continued to flourish and has focused us all on the best collective actions we can take going forward. 

For more information on crystal meth and where to get help in New Brunswick, click here.

Dr. Bill MacEwan runs the Urban Psychiatry Program at St. Paul’s Hospital in downtown Vancouver. He is the medical lead for the Downtown Community Court psychiatric teams. Dr. MacEwan is the clinical lead in the Hotel Study, a cohort study of the health, addiction and mental health of 500 residents of the Downtown East side in Vancouver. He has worked in the Downtown East side (DTES) of Vancouver for the last 19 years.

As a Clinical Professor in the Department of Psychiatry at UBC, he studies novel antipsychotics in the treatment of schizophrenia; he has also been looking at clinical correlates of schizophrenia, early psychosis and addiction.