Discuss two ways of assessing intoxication

These guidelines replace previous memoranda. They are intended to clarify:

• The roles and responsibilities of mental health service clinical staff in the assessment of drug/alcohol intoxicated persons.
• Issues concerning use of breathalysers in clinical practice.

They should be used as the basis for development of inter-agency protocols with drug treatment services.

Background

Alcohol and drug intoxication may influence a person's mental state presentation and may imitate or mask symptoms of an underlying mental or physical disorder. The resulting lack of inhibition and the depressant effect on the central nervous system may increase the risk of harm to self and others and exacerbate the risk of suicide. Coronial findings have emphasised the importance of mental state assessment in the presence of alcohol or drug intoxication.

Key principles

• Service staff should be aware of their responsibilities under relevant legislation and Departmental policy.
• The provision of mental health services is not dependent on sobriety, and is not restricted to situations in which there is a perceived risk of suicide.
• Breathalyser testing can be used in clinical situations with the patient's consent, but is not to be used to determine eligibility for service provision.

Implications for mental health service staff

The presence of alcohol and/or drug intoxication does not preclude early assessment, although it may indicate the need for further assessment when the person is no longer intoxicated. When a request for assessment is received, it is not appropriate to insist that the person be free from the effects of alcohol and/or drugs. This includes requests by police for assessment of persons held in police cells when there is a concern that mental illness or risk of suicide is present in a person who is also intoxicated. The coexistence of intoxication does not prevent assessment by Crisis Assessment and Treatment (CAT) services. This is emphasised in the Key Service Requirements for Enhanced (CAT) services and applies to the assessment of suicide risk and general mental state assessment.

Staff should familiarise themselves with Drug and Alcohol services in their local area to facilitate appropriate referral and collaborative interventions.

Relevant policy

The Key Service Requirements for Enhanced CAT Services (18/5/99) state:

The service will directly assess all persons referred from the community as being suicidal or who are identified as potentially at risk of suicide due to the presence of recognised risk factors, and ensure that they are rapidly responsive to such referrals on a 24 hour basis. This includes those who are intoxicated as a result of the consumption of alcohol or other drugs, and clients who do not require hospital admission or are not current clients of mental health services and may not require ongoing involvement with public mental health services.

Relevant legislation

The criteria for admission and detention as an involuntary patient are provided in section 8(1) of the Mental Health Act 1986. Section 8(2) provides that a person is not to be considered mentally ill by reason only of a number of factors including that the person takes drugs or alcohol (section 8(2)(k)).

Section 8(3) qualifies this:

sub-section 2(k) does not prevent the serious temporary or permanent physiological, biochemical or psychological effects of drug or alcohol taking from being regarded as an indication that a person is mentally ill.

It would be incorrect to assume that a person suffering, for example, from a severe schizophrenic illness or major depressive episode or situational crisis should be excluded from treatment because they have a high blood alcohol level. Intoxication may lead to an exacerbation of symptoms or deterioration in behaviour, necessitating greater intervention.

The fact that a person is under the influence of drugs or alcohol does not prevent recommendation if the criteria in section 8(1) are met.

Preliminary breath testing

Members of the police force have the power to administer a preliminary breath test under section 53 of the Road Safety Act 1986. Police do not have the power to conduct a preliminary breath test under other circumstances and should not be requested to do so by staff of mental health services. Breath testing may be used as a clinical tool where this is clinically appropriate. For example, it may be used during medical detoxification or as a means of monitoring patient compliance with the conditions attached to leave. It may also be used to monitor part of an overall treatment plan that includes abstinence or controlled alcohol intake. In these instances, testing is carried out with the consent of the person tested and is performed by clinical staff. Breath testing is not appropriately used to assess the value or necessity of clinical assessment.

Drug treatment services

Victorian drug treatment services provide secondary and tertiary specialist drug treatment services. These services are not emergency services and are unable to admit people on that basis.

The secondary and tertiary services provided include:

• Counselling, consultancy and continuing care
• Outpatient withdrawal, home-based withdrawal, residential withdrawal, rural withdrawal facilities
• Residential rehabilitation
• Peer support
• Youth outreach
• Specialist methadone services
• Alcohol and drug supported accommodation
• Koori community alcohol and drug services.

A number of statewide services provide specialist assistance to complement services provided at the regional level. These include:

• The Youth Substance Abuse Service (YSAS) which provides a 10 day residential respite facility.
• Outreach teams based at critical sites (Central Business District, Inner Western Suburbs, Bendigo, Latrobe Valley, Dandenong, Frankston, the Northern Suburbs and Box Hill) which operate with an after hours capacity.
• Ante- and post-natal support from the chemical dependency unit situated at the Royal Women's Hospital.
• The family drug rehabilitation program at Odyssey House.

Access to these statewide services is not available outside business hours Monday to Friday.

There are three services which provide a 24 hour service. These are:

• DIRECT Line - 9416 1818 or 1800 136 385 which provides a 24 hour telephone referral service to anyone in the community in need of information about drug and alcohol treatment services.
• DACAS (Drug and Alcohol Clinical Advisory Service) - 9416 3611 or 1800 812 804 which provides a 24 hour telephone service to health professionals with advice on the clinical management of drug and alcohol issues.
• Koori Sobering Up Centres which will also arrange to transport intoxicated persons to the Koori centre.

Treatment options

Treatment options available to clinical staff where a person is assessed as drug and/or alcohol intoxicated include:

• Admission to a mental health service if there is concern regarding mental state or suicidality.
• Referral to an accident and emergency department where there is concern regarding physical condition.
• Referral to police in the setting of offending or aggressive behaviour.
• Return home with provision of carer support or service review.

You are responsible for monitoring patrons for signs of undue intoxication. You are not required to count drinks or use a breathalyser but you should observe the patron's speech, coordination, balance and behaviour.

The amount of liquor that each person consumes before becoming unduly intoxicated varies. The signs of intoxication may be influenced by:

• gender
• age
• size
• health
• state of mind
• rate of drinking
• food consumed
• medication
• frequency of drinking.

Speech

Behaviour

Balance

Coordination

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You may consider the following indicators when assessing if someone is unduly intoxicated, but this is not a definitive list.

• Incoherent or muddled speech
• Loss of train of thought
• Rambling or unintelligible conversation
• Slurring words

• Bumping into or knocking over furniture or people
• Falling down or cannot stand
• Difficulty walking straight
• Staggering or stumbling
• Swaying uncontrollably
• Unsteady on feet

• Difficulty counting or paying money and fumbling change
• Difficulty opening or closing doors
• Dropping drinks
• Inability to find mouth with a glass
• Spilling drinks

• Aggressive
• Annoying/pestering others
• Argumentative
• Bad tempered
• Belligerent
• Confused
• Difficulty paying attention
• Disorderly
• Drowsiness or sleeping at a bar/table
• Exuberant
• Inappropriate sexual advances
• Loss of inhibition
• Loud/boisterous
• Not understanding normal conversation
• Offensive, including the use of offensive language
• Overly friendly
• Physically violent
• Rude
• Vomiting

If you note any of the above indicators in a patron’s conduct, assess if there could be causes other than intoxication. Speaking to a person about the possible causes for their signs of intoxication is important in meeting your obligations under the Liquor Act. It also ensures that you do not unlawfully discriminate against a person with mental or physical impairments.

Your observations of the quantity, rate and type of liquor consumed by a patron on the premises can help inform your assessment of whether that person is unduly intoxicated.

In the situation where you observe a patron has consumed little or no liquor at your venue but they are showing signs of being unduly intoxicated, they may have consumed liquor (or other intoxicating substances) before entering your venue, or you may not have seen their previous consumption at the premises. If they display indicators of undue intoxication and you have spoken to them to ascertain there are no other causes, you still have grounds for reasonable belief that they are unduly intoxicated.

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Also consider...

• Last reviewed: 25 Jun 2019
• Last updated: 26 Jun 2019