Chemical restraint

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A chemical restraint is a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient or in some cases to sedate the patient. Chemical restraint is used in emergency, acute, and psychiatric settings to perform surgery or to reduce agitation, aggression or violent behaviours; [a] it may also be used to control or punish unruly behaviours. [2] A drug used for chemical restraint may also be referred to as a " psychopharmacologic agent", " psychotropic drug " or "therapeutic restraint" in certain legal writing. [3] [4]

In the UK, NICE recommends the use of chemical restraint for acute behaviour disturbances (ABD), but only after verbal calming and de-escalation techniques have been attempted. It is viewed as superior to physical restraint, with physical restraints only being recommended for the administration of a chemical restraint. [b]

In the United States, no drugs are presently approved by the U.S. Food and Drug Administration (FDA) for use as chemical restraints. [5] Drugs that are often used as chemical restraints include antipsychotics, benzodiazepines, [6] and dissociative anesthetics such as ketamine. A systematic review in 2019 advised the use of intravenous haloperidol (a short half-life, first-generation antipsychotic) alone or in conjunction with lorazepam or midazolam (short half-life benzodiazepines), but said more research was needed. [c]

The Human Rights Watch wrote a report on the use of chemical restraints amongst the elderly in the US. It concluded that antipsychotic drugs are sometimes used almost by default to control difficult-to-manage residents. [2] The FDA estimates 15,000 elderly individuals in nursing homes die each year due to the unnecessary use of anti-psychotics. [7] According to the Nursing Home Reform Act, individuals have the right to be free from physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. [8]

The use of chemical restraint has been criticized. It is sometimes misused by health care workers for the convenience of the staff rather than the benefit of the patient, with workers using them to prevent patients from resisting care, rather than improving the health of the patient; [9] it can cause more confusion in patients, slowing their recovery; [10] and it can be unclear whether drugs used for chemical restraint are necessary to treat an underlying mental health condition or whether they are being used to sedate the patient. Patients can view chemical restraint as a violation of integrity and find the experience traumatic. [d]

Notes

  1. ↑ "Chemical restraint, also known as rapid tranquilisation, is the use of psychotropic medication to control severe agitation, or violent behaviours." [1]
  2. ↑ "Sedation (rapid tranquilisation) will be required to facilitate rapid intervention and institution of potentially lifesaving treatments if an individual displaying [acute behaviour disturbance] ABD fails to respond to de-escalation techniques. The rapid control and calming of an individual displaying the extreme physical exertion associated with ABD is essential to prevent further worsening of their metabolic status. Ideally sedation should be administered via the intravenous route; however, this route is unlikely to be immediately available." "Guidelines for the Management of Excited Delirium / Acute Behavioural Disturbance (ABD)" (PDF). Archived from the original (PDF) on 2020-11-01. Retrieved 2020-08-29.
  3. ↑ "While there is a sizeable, good quality body of RCT [randomized controlled trial] evidence regarding chemical restraint practices from around the world, the interventions, outcome measures, and findings are heterogenous and preclude more than simple description. On the current evidence base from RCTs, front-line clinicians could be advised to use haloperidol (alone or in combination with lorazepam or midazolam) delivered via IV, oral, or IM methods, to safely, speedily, and effectively control agitated, aggressive, and violent behaviours." [1]
  4. ↑ "Chemical restraint can furthermore be experienced as a violation of integrity and cause psychological discomfort"; [1] "Further, the individual experience of any form of restraint is well recognized as traumatizing and anti-therapeutic". [1] : 15 

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<span class="mw-page-title-main">Akathisia</span> Movement disorder involving a feeling of inner restlessness

Akathisia is a movement disorder characterized by a subjective feeling of inner restlessness accompanied by mental distress and/or an inability to sit still. Usually, the legs are most prominently affected. Those affected may fidget, rock back and forth, or pace, while some may just have an uneasy feeling in their body. The most severe cases may result in poor adherence to medications, exacerbation of psychiatric symptoms, and, because of this, aggression, violence, and/or suicidal thoughts. Akathisia is also associated with threatening behaviour and physical aggression in mentally disordered patients. However, the attempts to find potential links between akathisia and emerging suicidal or homicidal behaviour were not systematic and were mostly based on a limited number of case reports and small case series. Apart from these few low-quality studies, there is another more recent and better quality study that concludes akathisia cannot be reliably linked to the presence of suicidal behaviour in patients treated with antipsychotic medication.

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<span class="mw-page-title-main">Lorazepam</span> Benzodiazepine medication

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<span class="mw-page-title-main">Triazolam</span> Triazolobenzodiazepine class medication

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<span class="mw-page-title-main">Midazolam</span> Benzodiazepine used for anesthesia and procedural sedation

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References

  1. 1 2 3 4 Muir-Cochrane, Eimear; Oster, Candice; Gerace, Adam; Dawson, Suzanne; Damarell, Raechel; Grimmer, Karen (2019-09-09). "The effectiveness of chemical restraint in managing acute agitation and aggression: A systematic review of randomized controlled trials". International Journal of Mental Health Nursing. 29 (2). Wiley: 110–126. doi:10.1111/inm.12654. ISSN   1445-8330. PMID   31498960. S2CID   202406529.
  2. 1 2 ""They Want Docile"". Human Rights Watch. 2018-02-05. Retrieved 2020-08-29.
  3. ↑ "Physical restraint, medication and seclusion of persons receiving care, education or supervision in a school, institution or facility". General Statutes of Connecticut - Title 46a* Human Rights. Connecticut General Assembly. January 1, 2011. Archived from the original on 2016-03-09. Retrieved 2014-11-18.
  4. ↑ OFDT (15 February 2011). "Juvenile Federal Performance-Based Detention Standards Handbook" (PDF). Department of Justice. Retrieved 2014-11-18.
  5. ↑ Fleisher, G.R.; Ludwig, S.; Henretig, F.M. (2006). Textbook of Pediatric Emergency Medicine. Vol. 355. Lippincott Williams & Wilkins. pp. 1–1812. ISBN   9780781750745 . Retrieved 2014-11-18.
  6. ↑ DiMaio, T.G.; DiMaio, V.J.M. (2005). Excited Delirium Syndrome: Cause of Death and Prevention. Taylor & Francis. p. 125. ISBN   9780203483473 . Retrieved 2014-11-18.
  7. ↑ "ABC World News: Deadly 'Chemical Restraints' Kill California Nursing Home Patients - ABC News". abcnews.go.com. Retrieved 2014-11-18.
  8. ↑ State of Connecticut (8 March 2007). "RESTRAINTS" (PDF). Retrieved 2014-11-18.
  9. ↑ O'Donnell, J.; Ahuja, G.D. (2005). Drug Injury: Liability, Analysis, and Prevention. Lawyers & Judges Publishing Company. pp. 1–723. ISBN   9780913875278 . Retrieved 2014-11-18.
  10. ↑ Nay, R.; Garratt, S. (2004). Nursing Older People: Issues and Innovations. Churchill Livingstone. p. 246. ISBN   9780729537513 . Retrieved 2014-11-18.
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