While working with populations who use substances, psychologists may encounter patients who are intoxicated. In these situations, a variety of ethical and legal issues may arise, and often take precedence over direct clinical service. The purpose of this brief article is to provide some initial education as well as an overview of several common situations and factors psychologists may wish to prepare for and consider in their professional decision making when encountering an intoxicated patient.
Impairments in mental status and physiological changes are common with substance use. Intoxicated patients are particularly vulnerable as a result and special care should be taken. Safety should be paramount. In addition to fatality from overdose or physical injury, use of some substances in combination may result in a medical emergency due to effects on the body, such as depressing respiration.
Further, withdrawal from alcohol and benzodiazepine use can be fatal. Substance use has also been associated with adverse outcomes, including suicide. Professional decision making in such situations is complex and requires a well-thought out rationale which centers around risk management.
Managing of medical risk
Upon indication that a patient is intoxicated, it may be helpful to gather substance related information to the extent feasible, including the substances used, amount and frequency of use and the date and time of last use. If substance use has the potential to cause acute harm, ideally the patient may be referred to a detoxification appointment with a medical provider, such as their primary care physician.
Large medical centers may often offer these as same-day appointments. If the patient is using chronically and heavily, presents with or has a history of acute withdrawal symptoms, such as seizures, hallucinations or insomnia, or has a complex medical presentation or history, referrals to an urgent care facility with the proper resources, an emergency room or calling 9-1-1 are likely to be the safest and most appropriate option.
Throughout this process, the patient is likely to benefit from appropriate support and education. To the best of one’s ability and scope of practice, patients should be educated about the risks of use and withdrawal from the substances used. Proper releases of information should be completed if non-emergency referrals are made.
Management of transportation and public safety risks
An intoxicated patient driving presents a danger to self and the public that may potentially prompt mandated reporting. The psychologist should express these safety concerns to the patient and explore reasonable alternatives to reduce the potential for harm.
The psychologist may ask if the patient would be willing to turn over car keys temporarily, while arrangements are made for alternate transportation via a cab, ride sharing app, public transportation or family member/friend. If a patient insists upon driving, the psychologist may consider gathering available information, such as car make, model, color and license plate number. If a psychologist deems an impaired driver to be within mandated reporting responsibility, a call to a non-emergency or emergency police line may be appropriate.
Psychologists speaking with patients on the phone, who appear or report being intoxicated and indicate they are going to drive may be assessed to determine if they are an imminent risk. A welfare check or call to the local police where the patient lives may be appropriate or mandated.
Psychologists may consider including statements in their informed consent process about what may happen if patients engage in clinical encounters while under the influence of substances. Further, given the potential for complex clinical, ethical and legal consequences after the encounter, thorough documentation may be wise.
Specifically, document mental status, assessment of suicide and homicide risk and any actions taken and justification for such actions, other mandated reporting disclosures, substance use history, reported and observable signs of impairment or withdrawal symptoms, referrals made to medical providers or facilities, the patient’s mode of transportation to and from the appointment and the related transportation risk assessment.
Information provided and patient understanding about the risks of use and withdrawal from the substances used should be documented. Consultation with colleagues may be considered throughout the encounter, whenever appropriate, and possible and careful documentation should be made of these as well as the rationale and steps taken to protect the patient and public.
It is recommended that psychologists who anticipate such clinical encounters review applicable laws in their jurisdictions, as well as general principles and enforceable standards of The Ethical Principles of Psychologists and Code of Conduct that are particularly relevant to these scenarios. Psychologists employed in medical systems, group practices or other settings may already have procedures and policies in place to best utilize available resources and adhere to specific laws and standards of practice in their locations and settings.
Justin R. Gauthier, Ph.D., is a licensed psychologist and adjunct professor of psychology with specialization in addiction, traumatic stress, psychological assessment and program evaluation. He is available for consultation and can be reached at: JustinGauthierPhD@gmail.com.