What approach should be taken when training medical staff on the use of physical and chemical restraints for adult substance use disorder (SUD) clients with potential co-occurring mental health conditions or medical comorbidities?

Training Medical Staff on Physical and Chemical Restraints for Substance Use Disorder Clients

Core Reference Framework

The American Academy of Child and Adolescent Psychiatry's Practice Parameter for the Prevention and Management of Aggressive Behavior provides the most comprehensive framework for training staff on restraint use, emphasizing that repeated training is necessary to develop the high degree of competence this work requires. 1

While these guidelines were developed for psychiatric institutions, they establish the gold standard principles that apply directly to SUD populations, particularly given the high prevalence of co-occurring trauma and mental health conditions in this population. 2, 3

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Essential Training Components

Staff Training Requirements

Annual certification and repeated practice sessions are mandatory, not optional. 1

Your training program must include:

• Updated information on seclusion and restraint practices with annual recertification from academic, regulatory, patient advocacy, and professional resources 1
• Frequent hands-on practice in using restraint equipment, not just theoretical knowledge 1
• Training in documentation requirements including the 15-minute assessment protocol 4
• Annual cardiopulmonary resuscitation certification for all staff involved in restraint procedures 1
• Assessment of acuity levels to allow shift-by-shift staffing changes as needed for patient safety 1

Trauma-Informed Care Integration

Given that trauma history and PTSD are extremely common in SUD populations and associated with poorer treatment outcomes, your training must incorporate trauma-informed principles. 2, 3

• Staff must understand that restraint itself can cause or reactivate post-traumatic stress disorder with symptoms of flashbacks, nightmares, and intrusive thoughts 1
• Training should emphasize that restraints are a security measure, not a form of medical treatment, and should only be used as a last resort 1
• Staff need education on recognizing trauma responses and how restraint use may trigger these responses in SUD clients 3

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Strict Indications for Restraint Use

Restraints are indicated ONLY when the patient presents an acute danger to harm themselves or others, when significant disruption of the treatment program is occurring, and when less restrictive measures have failed or are not possible. 4

Prohibited Uses (Never Acceptable)

Staff must understand these are absolute contraindications:

• Never as punishment for patients 4
• Never for staff convenience or to compensate for inadequate staffing 1, 5
• Never by untrained staff 1
• Never where prohibited by state guidelines 1
• Never when the patient would be medically compromised by the restraint 1

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Physical Restraint Protocols

Safety Measures That Prevent Deaths

Between 1993 and 2003,45 deaths in child and adolescent psychiatric facilities were attributed to restraint use, making proper technique literally life-saving knowledge. 1

Critical safety protocols include:

• Supine positioning with head of bed elevated and free cervical range of motion to decrease aspiration risk 1, 4
• Continuous monitoring of restrained patients, not intermittent checks 1, 4
• Avoid prone positioning whenever possible, as deaths have been associated with its use; if absolutely necessary, monitor continuously for airway obstruction and minimize pressure on neck and back 1
• Never cover the patient's face or head 1
• Remove all smoking materials from the patient 1

Application Technique

Each limb must be wrapped with a protective collar before the restraint strap is applied to prevent direct pressure on skin and neurovascular structures. 4

• Restraints must be applied by trained staff who understand proper tension 4
• Use a minimum of two trained staff members per patient 6
• The bed should be bolted to the floor or sufficiently stable 6

Monitoring Requirements

Assessments every 15 minutes are mandatory for ALL restrained patients to evaluate: 4

• Extremity circulation and range of motion (skin color, temperature, capillary refill, pulses, sensation, ability to move digits)
• Vital signs
• Signs of injury due to restraint
• Nutrition and hydration status
• Physical and psychological status/comfort
• Airway patency and respiratory effort

If any signs of neurovascular compromise are detected, loosen or remove the restraint immediately - do not wait for the next scheduled assessment. 4

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Chemical Restraint Protocols

Definition and Appropriate Use

Chemical restraint is the involuntary use of psychoactive medication in crisis situations to help contain out-of-control aggressive behavior and must be distinguished from ongoing pharmacological management of underlying psychiatric illness. 4

Medication Selection

Benzodiazepines (e.g., lorazepam) are preferred due to fast onset and rapid absorption. 4

• Consider available medical and psychiatric history, including concurrent medications 4
• Document adverse responses such as dystonias or allergic reactions 1

Special Consideration for SUD Population

In cases of agitation due to suspected illicit stimulant use, chemical restraint may be preferable to physical restraint because rapid increase in serum potassium secondary to rhabdomyolysis from struggling can result in cardiac arrest. 1

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Regulatory Requirements

Licensed Independent Practitioner Evaluation

A licensed independent practitioner must evaluate the patient in person within 1 hour of restraint placement. 1, 4

Renewal Schedule by Age

• Patients <9 years: Renew every 1 hour 1
• Patients 9-17 years: Renew every 2 hours 1
• Patients >18 years: Renew every 4 hours 1

Documentation Requirements

All level 3 interventions must document: 1

• Circumstances leading to the restraint
• Review of failed de-escalation attempts
• Rationale for the type of intervention selected
• Notification of the patient's family
• Written orders for use
• Behavioral criteria for discontinuation
• Each verbal order by the licensed independent practitioner
• Each face-to-face evaluation and reevaluation
• 15-minute status assessments
• Any injuries sustained
• Duration of the episode
• Prevention suggestions for future incidents

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De-escalation as Primary Strategy

Each unit must have its own de-escalation program that helps patients manage angry outbursts, and these less restrictive options must be attempted before restraints are considered. 1

Training should emphasize:

• Anger management and stress reduction techniques 1
• Problem-solving strategies 1
• Psychoeducational approaches 1
• Recognizing triggers and warning signs specific to SUD populations 1

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Common Pitfalls to Avoid

Never assume restraints are appropriately tight just because they were initially applied correctly - patient movement or position changes can cause restraints to tighten over time, making objective assessment of circulation mandatory. 4

Do not delay loosening restraints if neurovascular compromise is suspected - the 15-minute assessment interval represents the maximum time between checks, not a suggestion to wait if problems are suspected. 4

Using restraints for staff convenience rather than patient necessity is both a regulatory violation and an ethical breach that your training must explicitly prohibit. 5

Inadequate monitoring can lead to complications including skin breakdown, neurovascular damage, rhabdomyolysis, kidney failure, and death. 1

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Organizational Structure

Clinical Oversight

All procedures must be approved by the medical staff of the facility with consideration given to state, federal, and regulatory mandates. 1

• Establish performance/process improvement teams to examine difficulties and improve effectiveness 1
• Maintain a seclusion and restraint log detailing each occurrence 1
• Collect data on each restrictive intervention including shift staff, length of episode, date/time, type of restraint, and any injuries 1
• Review inappropriate use immediately with mandatory additional training before staff participates in future episodes 1

Team Structure Options

Consider implementing: 1

• Code teams: Trained staff who manage all crisis situations (advantage: work well together; disadvantage: must be immediately available)
• Individual trained staff from different units who come together for de-escalation and restraint procedures
• Identification symbols on name tags indicating training level and credentialing to lead restraint teams

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SUD-Specific Considerations

Trauma-informed care approaches in SUD treatment have been underutilized in residential substance use treatment services, despite evidence showing improved outcomes. 2

Your training should address:

• The high prevalence of trauma history in SUD populations (associated with poorer treatment retention and outcomes) 2, 3
• How restraint use may retraumatize patients with trauma histories 1, 3
• The importance of empathy, compassion, and harm reduction strategies when working with SUD patients 7
• Recognition that multiple episodes of care are often necessary in the chronic disease model of SUDs 3