Should antipsychotics be stopped in a patient who is intoxicated?

Management of Antipsychotics in Intoxicated Patients

Do not routinely stop antipsychotics in intoxicated patients; instead, base your decision on the patient's cognitive abilities and clinical presentation rather than blood alcohol level alone. 1

Key Decision Framework

Initial Assessment Priorities

The American College of Emergency Physicians guidelines explicitly state that cognitive abilities, rather than a specific blood alcohol level, should be the basis for psychiatric assessment in alert, cooperative patients with normal vital signs. 1 This means:

• An elevated alcohol level does not automatically preclude continuing antipsychotic therapy 1
• Focus on the patient's mental status, vital signs, and ability to cooperate rather than laboratory values 1
• Consider a period of observation to determine if psychiatric symptoms resolve as intoxication resolves 1

When Antipsychotics Are Contraindicated in Intoxication

Antipsychotics should be avoided or withheld specifically when agitation is due to medical illness or drug ingestions with anticholinergic or sympathomimetic properties. 1 This is critical because:

• Antipsychotics have anticholinergic properties that can worsen anticholinergic delirium (e.g., from hallucinogens) 1
• Both conventional and atypical antipsychotics can exacerbate agitation in anticholinergic toxicity 1

When to Continue or Initiate Antipsychotics

For patients on chronic antipsychotic therapy who present intoxicated:

• Continue maintenance antipsychotics if the patient is alert, cooperative, with normal vital signs and no contraindications 1
• The primary concern is ensuring the patient can safely take oral medications and monitoring for adverse effects 1

For acute agitation in intoxicated patients:

• Benzodiazepines are first-line for agitation suspected to be due to intoxication 1
• If severe agitation persists despite benzodiazepines, consider adding a first-generation antipsychotic only after ensuring the intoxication is not anticholinergic in nature 1

Critical Monitoring Requirements

If antipsychotics are administered to an intoxicated patient, implement enhanced monitoring: 1

• Cardiorespiratory monitoring (all antipsychotics can prolong QTc interval) 1
• Pulse oximetry for respiratory depression risk 1
• Blood pressure monitoring for orthostatic hypotension 2
• ECG if patient tolerates it, given risk of QTc prolongation and torsades de pointes 1

Common Pitfalls to Avoid

Do not automatically discontinue chronic antipsychotics based solely on intoxication. 1 Abrupt discontinuation carries significant risks including: 1, 3

• Withdrawal dyskinesias and parkinsonian symptoms 1
• Dystonic reactions 1
• Risk of neuroleptic malignant syndrome 1
• Relapse of underlying psychotic disorder 3

Do not initiate antipsychotics for simple alcohol intoxication without psychiatric indication. 1 The 2016 Pediatrics guidelines (applicable to adults) clearly state antipsychotics are contraindicated for intoxication-related agitation alone. 1

Specific Clinical Scenarios

For patients with known psychiatric illness on maintenance antipsychotics who present intoxicated:

• Continue their home antipsychotic regimen if they are cooperative and can safely take medications 1
• Observe for 6+ hours to assess if symptoms are substance-related versus psychiatric 1

For new-onset agitation in an intoxicated patient:

• Use benzodiazepines (lorazepam 2 mg IM/PO) as first-line 1
• Reserve antipsychotics for psychiatric agitation that persists after intoxication resolves 1
• If antipsychotic is necessary, haloperidol 5 mg or risperidone 1-2 mg are evidence-based options 1