Let’s address the patients that come to the psych eval high, drunk, inebriated, stoned, etc. also known as the brick walls. I have some patients that will admit to everything and others who are in complete denial while slurring words. Regardless of the situation, try NOT to argue because it’ll make the situation worse. You just have to go with the flow and keep it simple.
The Red Flags?
The intake is already going to be difficult but whether the patient cooperates or not, here are my clinical red flags that something is WRONG or drug-induced:
- Nodding off, yawning, pinpoint pupils: I usually Rx test and let them know nothing schedule will be ordered until there’s a clean screen. I have patients admitting to doing all the drugs, agreeing to the Rx test, and anything else thinking they should be able to get a scheduled medication. NOPE, it just means that the patient needs to remain sober or consider rehab. Truly enforce a protocol so things don’t get worse.
- Uncontrolled crying spells and can’t confirm last ETOH use: yes, people cry all the time in psych but this is different. If the patient can’t confirm their last drink or has rapid anger/cry cycles, drooling/sobbing, I’m just going to assume that the patient drank right before walking in. Another flag is a patient being unnecessarily really loud, the skin is reddened/sweaty, which are also signs of recent use. At first, my patient said it was the AM then changed it to a few hours ago, and eventually was crying. Trust me with enough questions, ETOH patients are not going to be able to keep their stories straight and lash out…
- The SUPER Dilated Pupils (mydriasis): sometimes I’ll just simply ask, why are your pupils like this?? the patient may or may not be dumbfounded like it’s just normal but this could be a major sign of cocaine, BZD, LSD, MDMA..there’s a whole list of drugs that will super dilate your pupils. I mean it’s major to the degree that it looks scary so this isn’t like the regular coffee drinker or the typical ADHD use, but there are usually more red flags if there’s serious drug use.
Extra: loved ones/past providers expressing concerns, homelessness, frequent rehab/relapses, casually admitting to doing hard substances, personality disorders, unemployment, taking someone else meds known/unknown…These are people who usually struggle with substance abuse so you have to take extra precautions with prescribing and in general.
What to Focus On? The intake may not be complete, but you can at least try to cover some major areas. Think of this intake as a rough draft since the person isn’t in the clearest state of mind. Some people may cancel the intake, but you can still be accountable and can’t just discharge someone who’s possibly incapacitated. At a minimum, rule out any urgent issues (i.e. D.T.’s), call the county/ems or arrange transportation to an urgent care/hospital or to go back home.
The Intake is Basically What happened? and I usually just cut to the chase, what did you do? how much? last use? anything else? people who are really under the influence really can’t tolerate too many questions or details so just keep it simple as far as the communication. If there’s a visitor/family member present, they may know some information but overall, very little can be confirm or reliable. Don’t assume.
Current/Past Issues: mainly we are ruling out problems such as respiratory changes, injuries/pain, chest symptoms, etc., and ask about allergies, major conditions, and any kidney/liver problems. If the patient admits to having significant liver issues and is intoxicated, the person may need to be in the ICU. Also, covering the major bases in case EMS/hospital/misc staff have inquired.
A Plan: after making sure nothing serious is occurring, there still needs to be a plan depending on how intoxicated or whatever substance the patient is under:
- Very Intoxicated/Stoned: I usually just cover the basics, NO scheduled medications, and discuss the importance of sobriety and why the eval will be shortened. They can either go to a hospital, rehab, or home. Usually, the patient is with someone, but if the person is alone, you may have to consider calling EMS/county and some hospitals have their own EMS services and may pick up the patient…BUT the patient has to agree to these considerations, they are NOT mandatory. However, allowing an intoxicated patient to leave and get into an accident for example can possibly be a liability. If the person is drunk, belligerent, refusing everything…DOCUMENT and let the patient be d/c at their own risk and although this may not be the safest option, you can’t force a patient to be treated (in an outpatient clinic). Severe or recent opioid/heroin use is also in this category.
- Somewhat/Maybe Intoxicated/Stoned: These are my patients who are usually in denial, manipulative, or are minimizing the risks. I’m somewhat very strict with this group because it really shows they have a lack of control and are the most difficult to treat. They are frustrating. I have one patient who has yet to abstain from ETOH since being discharged from rehab months ago. The person keeps thinking sertraline is all that’s needed but continues to self-medicate. She doesn’t think the relapses of a little wine or whatever she uses is an issue and doesn’t want to increase or change her medication. So with this group, we still have to treat them like they’re normal but definitely be more strict with prescribing. Really be mindful of their liver and I usually recommend the patient to have a daily multivitamin. They’re really just a shot away from rehab…
- Denies Any Drugs or ETOH (for the day): these are my patients who did coke last week or went to a party and accidentally popped pills over the weekend but for today’s eval, everything is perfect. Yup, absolutely NO SCHEDULES. With all these people, they should be Rx tested but this group is definitely not getting anything until they can stay clean for more than a few weeks. This group also is usually threatening because they can’t understand why doing some cocaine or heroin at their birthday party is a problem or they want a pity party (time for a manipulation trick). They don’t understand too much of anything. Again don’t argue with them because they will lash out. I sometimes just start going over state laws and how I don’t want to go to prison. This isn’t a Burger King have your way operation. Truly enforce some boundaries or they need to seriously consider going back to rehab.
What else to do?
It’s outpatient so it’s not much else we can do but sort of play big brother. Mainly, to keep these patients safe from harming themselves but many will insist on learning the hard way. I had one patient who went directly to the hospital after his eval because he was too intoxicated to do anything else. I haven’t seen him since despite constantly being on my calendar, but I knew he still wasn’t sober enough or ready for any type of change.
Others will actually call me from rehab, and be more than willing to discuss a plan or understand the importance of being sober and truly humble themselves. So don’t beat the person up, they usually already feel terrible enough… Anticipate the relapses or the trial and errors and keep working out a plan to help the patient stay well.
