Crisis Response in Addiction Care

In addiction medicine, three situations require immediate response:

1. Overdose
2. Suicidal Ideation
3. Acute Withdrawal

Every healthcare provider working with this population must be prepared to respond.

Recognition

The Opioid Overdose Triad:

• Pinpoint pupils (miosis)
• Unconsciousness/unresponsiveness
• Respiratory depression (slow, shallow, or absent breathing)

Other Signs:

• Blue/gray lips and fingertips (cyanosis)
• Gurgling or snoring sounds
• Limp body
• Pale, clammy skin

Response Protocol

Step 1: Assess and Call for Help

• Check responsiveness (sternal rub)
• Call emergency services (108 in India)
• If available, call additional help

Step 2: Administer Naloxone

• Naloxone (Narcan) reverses opioid overdose
• Intranasal: One spray in one nostril
• Intramuscular: 0.4mg injection
• Repeat every 2-3 minutes if no response

Step 3: Support Breathing

• Rescue breathing if trained
• Recovery position if breathing resumes
• Stay with person until help arrives

Step 4: Post-Naloxone Care

• Person may wake up in withdrawal
• May be confused, agitated
• Naloxone wears off in 30-90 minutes
• Risk of re-overdose if long-acting opioid

Naloxone Access in India

• Available at government hospitals
• OST centers stock naloxone
• Community distribution programs emerging
• Harm reduction organizations provide training

Risk Factors in Addiction

• Active substance use
• Early recovery (first 90 days)
• Co-occurring depression/anxiety
• Recent loss (relationship, job, housing)
• Previous suicide attempts
• Access to lethal means
• Chronic pain

Assessment: The Columbia Protocol

Ask directly:

1. "Have you wished you were dead or wished you could go to sleep and not wake up?"
2. "Have you actually had thoughts of killing yourself?"
3. "Have you thought about how you would do this?"
4. "Have you had any intention of acting on these thoughts?"
5. "Have you done anything, started to do anything, or prepared to do anything to end your life?"

Response Protocol

Immediate Risk (plan + intent + means):

• Do not leave person alone
• Remove access to means
• Emergency psychiatric evaluation
• Call crisis line: iCall (9152987821)

Elevated Risk (thoughts, no immediate plan):

• Safety planning
• Increase support contact
• Reduce access to means
• Mental health referral
• Follow up within 24-48 hours

Lower Risk (passive thoughts):

• Validate feelings
• Explore protective factors
• Safety plan
• Schedule follow-up
• Provide crisis resources

Safety Planning

1. Warning signs (triggers)
2. Internal coping strategies
3. Social contacts for distraction
4. Family/friends who can help
5. Professional contacts
6. Means restriction plan

Opioid Withdrawal Timeline

| Timeframe | Symptoms | |-----------|----------| | 6-12 hours | Anxiety, cravings, muscle aches | | 12-24 hours | Sweating, runny nose, yawning, dilated pupils | | 24-48 hours | Nausea, vomiting, diarrhea, goosebumps | | 48-72 hours | Peak symptoms, insomnia, fever | | 5-7 days | Symptoms subside |

Medical Management

Buprenorphine Induction (preferred):

• Wait for moderate withdrawal (COWS ≥ 8)
• Start 2-4mg, titrate to comfort
• Transition to maintenance

Symptomatic Treatment:

• Clonidine for autonomic symptoms
• NSAIDs for pain
• Loperamide for diarrhea
• Ondansetron for nausea
• Sleep aids as needed

When Withdrawal is Dangerous

Benzodiazepine/Alcohol Withdrawal CAN BE FATAL:

• Seizures
• Delirium tremens
• Requires medical supervision
• May need inpatient detox

Opioid withdrawal is miserable but rarely fatal:

• Dehydration risk
• Aspiration risk if vomiting
• Risk of return to use
• Support and comfort measures

What AI Should Do

✅ Immediately recognize crisis keywords ✅ Provide emergency contact numbers ✅ Give basic safety instructions ✅ Alert human staff urgently ✅ Stay calm and supportive

What AI Should NOT Do

❌ Attempt to handle crisis alone ❌ Delay escalation to gather more information ❌ Provide specific medication dosing ❌ Dismiss or minimize concerns ❌ End conversation abruptly

📚 Learn More

• Explore overdose response with ChatGPT
• Discuss crisis intervention with Claude