Psychiatric patients line the hallways of the city’s emergency rooms, often arguing amongst one another and with themselves, awaiting a treatment that doesn’t yet exist.
A growing number of those patients are exhibiting psychosis tied to methamphetamine use, according to San Francisco emergency workers. But solutions are in short supply when it comes to meth addiction, with users of the drug frequently landing in psychiatric units with symptoms indistinguishable from schizophrenia.
The situation is placing workers already struggling with a revolving door of patients under heavy strain and raising the urgency for effective new treatments for meth use. Unlike opioids, there is no approved medication-assisted treatment for meth addiction, and patients are left to their own devices in the difficult process of quitting cold turkey.
Sean McGuire, a former meth user who now works as a nurse at Zuckerberg San Francisco General Hospital’s emergency unit, said that meth use plays a role in nearly every psychiatric admission and described seeing the same patients “over and over and over and over again.”
“When they come in, we find meth all over them and we’re told we can’t discard their property,” McGuire said. “So we put it in a bag and when they’re discharged they walk out with the meth and do it again.”
Emergency Workers in Crisis
McGuire’s account tracks with recent reports of psychiatric patients, unable to connect with long-term medical care, falling into a cycle of ambulance trips and ER visits that cost the city millions and can aggravate trauma.
The rate of emergency department visits resulting from meth use increased roughly seven-fold between 2010 and 2020, according to Department of Public Health data. The department did not provide up-to-date statistics on the percentage of psychiatric emergency visits that involve meth, but acknowledged that the drug is involved in a “significant number” of admissions due to its propensity to cause symptoms that mimic mental illness. The department reported in a 2018 document that 47% of patients visiting psychiatric emergency services were there because of meth.
Emergency workers say the situation has only grown worse. Heather Bollinger, another longtime nurse at General Hospital, said that the hospital’s staff and facilities are ill equipped to handle the influx of meth users in psychosis. The de-escalation techniques traditionally used to calm emergency psychiatric patients often don’t work on a highly agitated meth user, nurses say.
“I can’t think of a worse place for someone to be in when they’re already overstimulated. If you’re paranoid, imagine being surrounded by doctors and nurses,” Bollinger said.
The crisis in the city's emergency units played a role in recent protests by mental health workers and led some nurses to join a recent City Hall hearing to lambast the Department of Public Health for failing to properly staff their units.
“In my earlier years, I knew I would be spit at and maybe people would throw stuff. But I didn’t fear that I would be grabbed, kicked, punched and thrown to the ground,” Bollinger said. “That is happening now.”
‘White Man’s Drug’ Goes Mass Market
The surge in meth-related hospital visits in San Francisco coincided with a gradual rise in the purity of meth seized by the federal Drug Enforcement Administration.
That evolution dates back to a 2005 law that made it more difficult to buy Sudafed, which was once commonly used to cook meth in the U.S., according to Wade Shannon, a special agent in the Drug Enforcement Administration’s San Francisco Division.
Drug cartels capitalized on the change by importing chemicals from China and mass-producing meth in Mexico, said Shannon. Methamphetamine seizures at the California-Mexico border have ballooned in recent years alongside a decline in the number of domestic meth labs.
“They locked all the shelves and locked all the pills up and the cartels started working with chemical suppliers from Asia,” Shannon said. “They can produce huge quantities of meth and with that, increase the purity. With the purity came a lot of chronic meth users.”
As a result of the mass production, prices dropped and made the drug more widely attainable. Phillip Coffin, director of the Center on Substance Use and Health and author of the city’s annual substance use trends report, said that many people in San Francisco who had previously used cocaine shifted to meth around 2009.
“It was a white man’s drug back in the day. Then it went from $1500 an ounce to $250,” said an unhoused meth user living in SoMa who goes by Dusty.
Some people living on the streets said they also have practical reasons for using the drug. A woman who gave the name Sallie said that she uses meth so she can stay awake to protect herself at night.
“I look good, I’m a pretty female,” Sallie said. “When I get a place I’ll stop using [meth] because I won’t have to worry about staying up.”
But Sallie also noted the dangers of prolonged use. She said her ex-fiance stabbed her with a pencil and was eventually forced by the city into an involuntary hold after falling into a meth-induced psychotic episode.
Old Drug Shows New Promise
An anti-depressant called Mirtazapine has been used for years to treat depression, obsessive-compulsive disorder and other conditions. A team of researchers in San Francisco believe the drug could also provide a way out for people addicted to meth.
An ongoing research experiment funded by the SF Department of Public Health has found that the medication is linked to a 30% reduction in drug use among trial participants, according to Coffin.
If ultimately approved by the Federal Drug Administration, the treatment could help people struggling to wean off the powerful stimulant and bring badly needed relief to overloaded emergency departments.
“Use Meth?” reads an advertisement for the study around town. “Help contribute to finding the first potential FDA-approved medication for meth use.”
In exchange for up to $2,430, patients participating in the study submit to a two-week hospital stay, during which they are tested for any negative side effects that could arise from combining Mitrapazine with meth, opioids or other medications.
Coffin said that his team has detected no issues during the first two trials of the drug’s efficacy. Completion of the current trial phase would prompt larger-scale testing as the final qualification for FDA approval.
“It was the first time in two separate studies that medication has shown a benefit for this challenging condition,” Coffin said. “A big thing about developing a medication is overcoming the stigma and actually treating it as a disorder.”
According to Coffin, the most effective treatment available as of now is called contingency management, which entails giving meth users money to stay sober. But the practice is also controversial: Gov. Gavin Newsom vetoed a bill that would have expanded the practice under MediCal in 2021.
A treatment can’t come soon enough for emergency medical workers, who say that overburdened hospitals can’t be the first line of defense in the city’s overlapping drug and mental health crises.
“We’re doing emergency admissions for people that just need a place to sleep it off,” McGuire said.