What are the guidelines for using pharmacological restraint, including medication options and dosages?

Guidelines for Pharmacological Restraint

Pharmacological restraint should be used only to prevent dangerous behavior to self or others and to prevent serious disruption of treatment programs, after less restrictive options have failed or are impractical. 1

Definition and Indications

• Chemical restraint is the involuntary use of psychoactive medication in a crisis situation to help a patient contain out-of-control aggressive behavior 1
• It must be distinguished from the pharmacological management of a patient's underlying psychiatric illness 1
• Pharmacological restraint should never be used as punishment, for staff convenience, or to compensate for inadequate staffing 1

Assessment Before Administration

• Consider available medical and psychiatric history, including concurrent medications being used 1
• Check for potential drug interactions with current medications or illicit substances (e.g., combination of phencyclidine and haloperidol may promote hypotension) 1
• Evaluate for contraindications based on medical conditions (e.g., avoid anticholinergic antipsychotics in patients with severe asthma) 1

Medication Options and Dosages

First-Generation Antipsychotics

• Haloperidol:

  • Adults: 0.5-2 mg PO/IM for moderate symptoms; 3-5 mg PO/IM for severe symptoms 2
  • Geriatric or debilitated patients: 0.5-2 mg PO/IM 2
  • May cause extrapyramidal symptoms (EPSEs) and dystonic reactions 1
  • Do not use in patients with Parkinson's disease or Lewy body dementia 1

• Chlorpromazine:

  • 12.5-25 mg PO/PR; can be given q6h-q12h if scheduled dosing required 1
  • Use lower doses in older patients 1
  • Sedating with anticholinergic effects; may cause orthostatic hypotension 1

• Levomepromazine (Methotrimeprazine):

  • 5-12.5 mg PO/SC; can be given q2h PRN 1
  • Use lower doses (2.5 mg) in older or frail patients 1
  • Sedating with anticholinergic effects 1

Second-Generation Antipsychotics

• Olanzapine:

  • 2.5-5 mg PO/SC/IM 1
  • Reduce dose in older patients and those with hepatic impairment 1
  • May cause drowsiness and orthostatic hypotension 1

• Quetiapine:

  • 25 mg (immediate release) PO; can be given q12h if scheduled dosing required 1
  • Reduce dose in older patients and those with hepatic impairment 1
  • Less likely to cause EPSEs than other antipsychotics 1

• Risperidone:

  • 0.5 mg PO; can be given up to q12h if scheduled dosing required 1
  • Reduce dose in older patients and those with severe renal or hepatic impairment 1

Benzodiazepines

• Lorazepam:

  • 0.5-1 mg PO/SL/IV/IM q4h PRN; maximum 4 mg in 24 hours 1
  • Reduce dose to 0.25-0.5 mg in elderly or debilitated patients; maximum 2 mg in 24 hours 1
  • May be preferred for alcohol or benzodiazepine withdrawal 1

• Midazolam:

  • 2.5-5 mg SC/IV q1h PRN 1
  • Use lower doses (0.5-1 mg) in older or frail patients or in patients with COPD 1
  • Faster onset of action compared to haloperidol alone 3

Combination Therapy

• Haloperidol plus promethazine:

  • More effective than haloperidol alone in terms of speed of onset and safety 3
  • Reduces risk of acute dystonia compared to haloperidol alone 3
  • Combination of haloperidol (5-10 mg) plus promethazine (25-50 mg) produces more rapid tranquilization than lorazepam alone 4

• Benzodiazepine plus antipsychotic:

  • If agitation is refractory to high doses of neuroleptics, consider adding lorazepam 0.5-2 mg every 4-6 hours 1
  • Combination may be preferred for patients with suspected schizophrenia, mania, or psychotic depression 5
  • Caution: fatalities reported with concurrent use of benzodiazepines with high-dose olanzapine 1

Administration Protocol

• Offer oral medication before intramuscular injections whenever possible 1
• Administer on a stat or emergency basis and continuously monitor by trained nursing personnel 1
• Document the rationale for use of single versus multiple medications 1
• Review the impact of chemical restraint medications on other medications the patient is currently using 1
• If possible, obtain approval from parent or legal guardian in advance (for minors) 1

Monitoring Requirements

• Continuously monitor for allergic reactions, paradoxical reactions, dystonias, extrapyramidal side effects, and neuroleptic malignant syndrome 1
• Continue monitoring until the patient is awake and ambulatory 1
• A licensed independent practitioner must have face-to-face contact with the patient within 1 hour of the initial order for restraint 1
• For Medicare/Medicaid-funded programs, a physician or licensed independent practitioner must conduct a face-to-face evaluation within 1 hour of initiation 1

Special Considerations

• PRN (as needed) use of chemical restraints is prohibited 1
• With anxiolytics and antihistamines, be aware of the risk of paradoxical increase in rage 1
• Patients who are medicated for acute management of aggression often benefit from decreased stimulation in a time-out room 1
• For children and adolescents, doses should be lower and titrated more gradually 1, 2

Common Pitfalls to Avoid

• Using chemical restraint as punishment or for staff convenience 1
• Administering medication without considering drug interactions or medical contraindications 1
• Failing to offer oral medication before resorting to intramuscular injection 1
• Inadequate monitoring for side effects and adverse reactions 1
• Mistaking agitation for pain, resulting in higher doses of opioids which may exacerbate delirium 1

By following these guidelines, healthcare providers can ensure that pharmacological restraint is used appropriately, safely, and only when necessary to prevent harm to patients or others.