What is considered a chemical restraint?

Definition of Chemical Restraint

Chemical restraint is defined as a medication used to control behavior or to restrict a patient's freedom of movement that is not standard treatment for the patient's medical or psychiatric condition. 1, 2

Key Characteristics of Chemical Restraint

• Chemical restraint involves the involuntary use of psychoactive medication in a crisis situation to help a patient contain out-of-control aggressive behavior 1, 3
• It is distinct from ongoing medication used to treat symptoms of underlying psychiatric illness 2, 4
• Chemical restraint is considered a security measure, not a form of medical treatment, and should only be used as a "last resort measure" 1
• The effects of chemical restraint (sedation) can persist for hours to days, far longer than required for the patient to regain self-control 1

Indications for Chemical Restraint

• Prevention of dangerous behavior to self or others 1, 4
• Prevention of serious disruption to the treatment program including considerable disruption of property 1, 3
• Management of acute agitation that poses immediate safety risks 4, 5
• When other less restrictive measures have failed or are not possible options 1
• In cases of agitation due to suspected illicit stimulant use, chemical restraint may be preferable to physical restraint due to risk of rapid increase in serum potassium from rhabdomyolysis 1

Inappropriate Uses of Chemical Restraint

• As punishment for patients 1, 3
• For the convenience of staff or the program 1, 2
• To compensate for inadequate staffing patterns 1, 3
• Where prohibited by state guidelines 1
• By untrained staff 1, 3

Administration Protocol

• Before administration:

  • Review the patient's medical and psychiatric history 1, 3
  • Consider potential drug interactions with current medications or illicit substances 1, 3
  • Obtain parent/guardian consent when possible 4

• During administration:

  • Offer oral medication before resorting to intramuscular injection 1, 4
  • Ensure patient is sitting or standing to avoid aspiration 1
  • Administer on a stat or emergency basis 4, 3

• After administration:

  • Continuous monitoring by trained nursing personnel is required 1, 4
  • Monitor for adverse effects including allergic reactions, paradoxical reactions, dystonia, and extrapyramidal symptoms 4, 3

Regulatory Requirements

• A licensed independent practitioner must have face-to-face contact with the patient within 1 hour of the initial order 1
• The treating physician must be consulted as soon as possible if not the practitioner who ordered the restraint 1
• Documentation must include rationale for medication choice and impact on other medications the patient is taking 4
• Orders are time-limited based on patient age 1, 4

Common Pitfalls and Safety Considerations

• Benzodiazepines may cause respiratory depression, especially when combined with other CNS depressants 4
• Antipsychotics can cause QT prolongation, extrapyramidal symptoms, and dystonic reactions 4, 3
• With anxiolytics and antihistamines, be aware of the risk of paradoxical increase in rage 3
• Inadequate monitoring for side effects and adverse reactions can lead to serious complications 3, 6
• Mistaking agitation for pain may result in inappropriate medication selection 3

Medication Options Commonly Used for Chemical Restraint

• Benzodiazepines (e.g., lorazepam) - preferred due to fast onset, rapid absorption, and no active metabolites 4
• Antipsychotics (e.g., haloperidol) - most evidence-based conventional antipsychotic for agitation 4, 5
• Combination therapy of a benzodiazepine plus an antipsychotic is frequently used for acutely agitated patients 4, 5
• Newer atypical antipsychotics have limited evidence for use in chemical restraint 1

Chemical restraint should always be considered a last resort intervention after less restrictive options have been exhausted, with the primary goal being to ensure safety while respecting patient dignity and autonomy 1, 7.