Friday, July 10, 2009

Earth to Psychiatry: Let Patients Smoke

Susan's When You're Going Through Hell Keep Going blog comments on a Newark (NJ) Star-Ledger item that reports:

"Beginning today, smoking will be banned in all areas of the Greystone Park and Ancora psychiatric hospitals, with similar bans to follow at three other state psychiatric facilities ..."

Smoking is already prohibited inside all state psychiatric hospitals in New Jersey. Says Susan:

"I would like to know what genius convinced Governor Corzine this is a good thing. They sure as hell didn't ask me. I have been in private and public hospitals - and what do you do in them? You smoke."

Susan goes on to say:

The last time I was in a hospital, the smokers were going off the wall, craving their cigarettes. The nurses were giving them patches, but the thing is about a patch, you want something to hold in your fingers, to put in your mouth, to shake into an ashtray, to grind the butt down. It's not just the process of lighting the cigarette, putting it to your lips and inhaling, it's everything.

Take it away from people in psychiatric hospitals, what do you get? A bunch of unhappy smokers who are forced against their will to wear patches and crave a cigarette. They get unhappy. They snap at the doctors, and nurses. They are miserable, crabby, and just not pleasant to be around.

According to the Star-Ledger article, the ban was instituted in the name of "wellness and recovery." According to an official, quoted in the article: "Our intent is to increase the life-spans of our patients, not to shorten them."

Ahem. Excuse me. I have a friend here in California. Last year, hospital staff picked a fight with her brother, Jeffrey, age 25, over whether he could have a cigarette break. Staff decided to show him who was boss. He was placed in five-point restraints, belly down, where he died.

Earth to psychiatry: Let patients smoke.

Individuals are admitted to psychiatric facilities in a state of crisis, generally in extreme agitation and often traumatized by a very recent event. They find themselves - usually against their will - in a strange environment that they rightly perceive as threatening.

Locked units with buzzing doors, strange people, police walking in and out, uniformed security, burly men poised for a takedown ...

So what do authorities do? They take away the patient's one comfort, the one thing that may help them settle into their new environment.

Psychiatric hospitals exist to take an individual out of crisis and move him or her into a state of conditional stability before sending them back out into the street, typically disoriented and confused. Patients don't get "well" in these settings. But they need all the help in the world getting them through the experience.

How misguided is psychiatry? The same profession that purports to be concerned about the patient's long term health when it comes to nicotine is the same profession that puts them on meds that demonstrably shorten their life spans over the long term.

Sorry for raving, but this hypocrisy bugs the hell out of me.

Last year I was in New Jersey, giving a ground rounds lecture at a private psychiatric facility in Princeton. No Smoking signs were all over the grounds. My talk was on meds compliance, and part of my prepared message included the fact that as opposed to the low compliance rates for meds over the long term (because they leave an awful lot to be desired), tobacco has a 100 percent compliance rate (because it works).

One reason that most people with schizophrenia and bipolar crave cigarettes is because for the brief time a cloud is in their lungs, their head clears up. People with schizophrenia in particular have difficulty filtering out distractions, which interferes with their ability to think. This changes when nicotine molecules lock onto the neuron's alpha-7 nicotinic receptors.

In the drug development pipeline are nicotinic agonists.

Patients are sending a message loud and clear, I told the psychiatrists and therapists in the audience. They will take a drug that works, even one with the worst side effects profile in the world.

I happened to jokingly add that maybe they should be prescribing cigarettes to their patients. I also called them out over the No Smoking signs I saw on the hospital grounds.

My audience showed their appreciation by emptying the room as soon as my lips stopped moving.

Psychiatrists I have talked to in private also don't get it. They have been conditioned to believe that smoking is a bad thing - which it is - that should not be encouraged. They forget that there is a crucial distinction between short-term and long-term treatment. Getting a person out of crisis is not the time to be worrying about what may or may not occur a quarter century from now. That's why doctors overmedicate with drugs that are blatant metabolic and diabetes risks. That's why patients should be allowed to smoke.

You don't facilitate getting a patient through a crisis and moving toward stability by taking their one security blanket from them.

(Recovery Innovations, based in Arizona, seems to be the one exception. At the emergency facility they operate in Phoenix, they have a policy of zero restraints. Significantly, they allow patients to smoke.)

Long-term care is a different kettle of fish. You leave the patient on high side effects meds only if you have to. You promote good diet, exercise, and all the rest. If the patient is smoking, you encourage various smoking-cessation regimens, when the patient is ready.

Sorry for raving on. I never smoked. I hate idiots who think they have a First Amendment right to blow fumes in my face. But what I hate worse is innocent people dying alone in five-point restraints, all because of an argument over a cigarette.

If Jeffrey had been allowed to have his smoke, he would be alive right now.


Elizabeth said...

What a horrifying story! Were the staff and/or the hospital charged with his murder?

John McManamy said...

Hi, Elizabeth. They should be, but you know that won't happen. I will be following up on this in future blogs.

susan said...

Thank you very much for understanding and the shout out, John.

Love to you and sweet Bullwinkle.

megs said...

AMEN !!!!! YES !!! The one time I was in the Mental Health Unit, we were allowed to smoke. Then it changed, and the patients are only allowed to smoke, according to the schedule on the wall. The patients go outside to an enclosed area, with a wire roof - to prevent escapes - and a staff person has to stay with them, even though there's a camera out there.

Because of the smoking rules, I have done everything in my power to prevent another hospitalization.

I hate it that my smoking has been legislated out of my life. I've gotten used to the local restrictions, but damn, don't put me in the Unit, without my cigarettes.

Anonymous said...

My 21 yr-old son has a fairly severe case of OCD. He has recently taken to smoking cigarettes, which I naturally thought was a bad idea. He says they relax him a lot, unlike any of the meds he has been prescribed. Do you know anything about this? Is there any research going on?

John McManamy said...

Hey, Anonymous. I'm out of my depth here. As a general rule - smoking should not be used as a crutch. There are other relaxation tools such as yoga, breathing, taking walks, hot baths, etc. But there is also another general rule called listening to your son. Maybe you two can come to this arrangement: You will listen and acknowledge where he's coming from provided you are free to challenge him.

Chances are the two of you already have this arrangement. You are both learning (as are we all). Keeping the dialogue going is what's important.

Evan said...

Oh, and those who instituted this ban don't do things like: drink alcohol, eat fast food, drive too quickly . . . The wealthy and powerful are always moralising about the faults of the poor - while ignoring what they could do about it (like listening to their pain and changing the institutions, in this instance).

AliceT said...

Thanks for this, John. It is cruel to take the cigarettes and nicotine away from mentally ill persons, especially when they are in crisis. It helps tamp down the anxiety and psychotic thinking....the professionals, and loved ones need to listen to the people who are living it or have lived it about this.

Anonymous said...

I was in a non-smoking hospital last year. There was smoking ban on the entire hospital campus, including the psych ward. The people on inpatient were given patches like in other facilities. I moved over to the day unit with some smokers and interestingly, every one but one of them chose to keep the patch and not smoke anymore. The other patients cheered them on and supported them through giving up the cigarettes. One man even brought me (a non-smoker) his last pack to dispose of for him. After 2 month stay on the day unit I saw many people completely kick the habit. I can understand how stressful the non-smoking policies can be, but I actually saw it do good for a handful of people. Most of them said it was a great time to quit as they had lots of distractions and support from the staff and patients. Only one person went back to smoking and ironically he was a nurse on staff at that very hospital in the cardiac unit. Smoking bans don't always have to be a bad thing.

Anonymous said...

i am an employee on one of those units that is trying to decrease and eventually phase out smoking- my office is practically filled with smoke each time there is a break for the smokers- and the hospital can't do anything to protect my health!
i understand the smoking thing- i grew up with two parents who smoked, but i am an asthmatic and we do work in HEALTH CARE, we don't, in our facility allow others to smoke, and being in any part of a hospital is stresful!

Anonymous said...

I cannot agree with allowing psych patients to smoke, shoot heroin (hey, that feels pretty good, too!), or otherwise continue to harm themselves WHILE THEY ARE IN HOSPITAL. That is the time to not smoke, they can use NRT's,or not, but no, they should not be allowed to further damage themselves.
I'm a healthcare worker in a smoke-free environment.

An said...

I was hospitalized for depression/bipolar about 15 years ago. The hospital held me for a month (i.e., until my insurance ran out). At the time, I was a chain-smoker, and I really found that smoking calmed my jangling nerves like nothing else. One of the interesting things I noticed was that during group therapy sessions, my fellow inmates and I mainly stared at our shoes.

On smoke breaks, though, we automatons suddenly turned into people. We talked, bitched about the incompetent and arbitrary behavior of the staff, laughed, told our stories, formed friendships – in short, we felt human. Somehow, that shot of nicotine seemed to jolt us out of mental cages, if only for 15 closely-supervised minutes at a time.

Sure, the toxins in the cigarettes were probably as dangerous as those in the hospital cafeteria food. I realize that curtailing this type of behavior is done in the best interests of the inmates (or patients, or clients, or whatever they’re calling us these days), as well as that of the staff. But I’d also recommend that those calling for a ban on smoking in hospitals look at entire situation in its REAL-LIFE context.

Anonymous said...

Finally, Susan... Someone who gets it! First it's the Mental Health Workers themselves who convince you that you should buy your Son with Schizophrenia cigarettes because the affects of the nicotine will help him. Not to do so would be cruel. Then 3 years later after they are hooked on cigarettes and in crisis and have to be admitted to the hospital to "hopefully" get the help they so desperately need... They are cut off from their cigarettes cold turkey! The one thing that helps calm the voices! I have never smoked a day in my life so don't get me wrong, I am in no ways promoting smoking with the mentally ill... BUT... Get them out of crisis first and then slowly work them off cigarettes!! BTW... My Son was killed recently at a hospital and I am STILL waiting for the autopsy results. He was the apple of my eye and I will never look at the world the same way again!!

Our Mental Health system is horibly messed up!! It is the very people who are suppose to understand and care about people with Mental Illness that don't have a clue or just plain don't care!! :o(

Susan, I am SO very, very sorry for your loss of Jeffrey and I can say I totally understand how you feel and "I" get it too!!!!! "D"