Intoxication has a wide range of definitions. Some agencies will define someone as intoxicated if they simply smell of alcohol. Others will define it according to behavioural signs, such as slurred speech or staggering gait. Some services will use breathalysers to determine if pre-set level has been breached (e.g. 0.05mg%).
Obviously, the risks and challenges of managing someone who has had a “couple of beers” will be different from someone who has potentially overdosed, indicating that there is a need for various approaches. Admission and management policies will vary based on degree of intoxication, associated risk, agency philosophy, resources and expertise.
Intoxicated clients may present with behavioural problems that require management (e.g. they might be aggressive or they may need medical assistance), or service rules may exclude them from entry to the service.
Upon encountering someone who is apparently intoxicated, the first step is to ascertain whether they are indeed experiencing alcohol or other drug intoxication (or perhaps a combination of alcohol/drugs). It is important to remember that there are various physical and mental health conditions that can result in symptoms similar to AOD intoxication. Therefore, do not automatically assume that someone is intoxicated if their movements are staggered or their speech is slurred. Consult Signs and symptoms to assist in identifying whether a person’s condition might involve AOD intoxication. More detailed information on the short term effects of different drugs is available from the Australian Drug Foundation “How Drugs Affect You” series of pamphlets (check their catalogue at http://www.adf.org.au). If you believe that the person is experiencing a psychiatric emergency, consult Psychiatric emergencies. Emergency medical services should be called where indicated (e.g. head injury; overdose; loss of consciousness).
If the individual is unconscious or falls unconscious while you are present, then emergency assistance should be provided immediately. An ambulance should be called and there might be a need to administer first aid and possibly CPR. This is a good reason to try to ensure that at least some staff in the agency are provided with first aid training/accreditation. The hospital assumes responsibility for the individual once they are transported to their facility. If necessary, they may arrange AOD treatment during the hospital stay, or they may release the person to accommodation support or outpatient services who will then need to follow-up with case support.
Steps to take if someone has overdosed (see Developing protocols for managing emergencies):
Some people who are intoxicated may exhibit mental health symptoms such as anxiety, depression or psychosis, depending on individual factors and the type of drug(s) used. Many symptoms will diminish as the level of intoxication reduces. However, other symptoms, associated with withdrawal, may emerge (for example, someone who is intoxicated with amphetamines may be anxious and/or agitated. As they move into withdrawal, they may become depressed for a time). Many low level symptoms can be managed by ensuring access to a safe, secure and quiet environment with some degree of monitoring and supervision. It might be worth examining if you can provide access to such an environment in your agency or through referral to another service.
More severe and enduring symptoms will require specialist referral and management. It will be useful to contact local mental health services to help develop protocols for occasions when referral is required. If it is believed that the intoxication and/or mental health problems increase the risk of aggression and/or violence, refer to the section below.
Some people who are intoxicated may be at increased risk of self-harm. Risk may be elevated because of factors such as impulsivity or depression associated with intoxication. You should refer to the agency’s protocols on self-harm if you suspect there is a risk. If your agency does not have such protocols, it is important to develop them.
If the person is violent or aggressive, conflict avoidance strategies are recommended. These include:
In the case of extreme psychosis or agitation, there may be an increased threat of physical injury to the individual or yourself, which will make it necessary to follow agency protocols, for example by calling the police. In these cases it is essential that you consider your own health and safety, which may mean:
In such situations, it is advised that you contact the police immediately. Once the police arrive, they will be responsible for assessing the condition of the person and transporting them to either a sobering up shelter or supportive accommodation. Note that intoxication in a public place or possession of an illegal drug may be grounds for a criminal conviction (see Legal issues).
After any incident, it is worthwhile reviewing how any incident or emergency was managed, provide staff support and debriefing and review and, if necessary, adapt protocols and procedures.
If the person is responsive and calm, then they should be asked if they are okay. This should be followed up with questions such as, ‘have you been drinking’ or ‘are you high’ as a means of determining whether they are intoxicated. Visual cues outlined in the information sheet on signs and symptoms should also be used in reaching a determination of their current state. If it is deemed that the person is intoxicated, and not safe or eligible to access or remain in your service, then they should be assisted to the nearest sobering up shelter (or other designated place) if one is available or some other safe place, such as a friend or relative (remember that you will need to consider the well-being and safety of the person who is accepting responsibility. For example, your actions should not increase the risk of domestic violence.
If your service has rules about not admitting or working with clients who are intoxicated, it is important to communicate that you are concerned about the intoxication and/or behaviour, not that you are rejecting them as an individual. You could communicate this by saying something such as: ‘John, as you are aware, we have a rule about not meeting with people when they are intoxicated. However, I would like to see you tomorrow when you are sober. Perhaps I can help just now by helping you find a safe place to stay tonight.’
If you do admit an intoxicated client, you will need to ensure that you have protocols to ensure the safety of staff and clients. These will include strategies to prevent and manage disruptive incidents and ensure the safety and well-being of clients. As some problems associated with gross intoxication may require medical management, it will be important to review service capacity (e.g. consult with specialist drug and alcohol or other health services) as part of your decision-making processes about admitting intoxicated clients.
Note: It is important once the needs of the intoxicated person have been addressed, that the area is cleared of any substances, needles, bottles and other items that may present a safety hazard. Consult the guidelines on standard precautions.
As part of helping people it can be important to find secure shelter. For example, a safe place for an intoxicated person may include a sobering-up shelter. Alternatively, if the individual already has accommodation, then the contact details of a responsible individual known to the person could be obtained so that they can be collected. Alternatively, assistance could be provided to return home using public transport (you will need to assess their ability to safely navigate transport systems and any risks if they live alone. The level of intoxication will be one important factor in your decision-making).
If an individual does not have safe and secure accommodation, they could be directed to the nearest accommodation support provider. Telephone services in most states and territories can supply a list of providers and their availability for clients. Some of the services available for referrals (in some cases, metropolitan areas only) are as follows:
Victoria — Crisis Help Network, ph. 1800 627 727 (10am to midnight 7 days)
New South Wales — Homeless Persons Information Service, ph. 1800 234 566
Queensland — Smart Service, ph. 1800 474 753
Western Australia — Homeless Helpline, ph. 1800 065 892; Crisis Care, ph. 9223 1111 or 1800 199 008; Salvation Army Care Line, Ph. 9227 8655.
South Australia — FAIRS, ph. 1800 003 308; (after hours) Crisis Care, ph. 131 611
Northern Territory — A list of Supported Accommodation Assistant Program (SAAP) Providers are provided on the NT government website.
Tasmania — SAAP information service, ph. 1800 800 588
Australian Capital Territory — Canberra Emergency Accommodation Services, ph. 6230 1486
You may decide that your client will benefit from help from elsewhere (e.g., legal service; GP; financial advice; relationship advice; supported accommodation). The evidence indicates that a proportion of people with alcohol and other drug problems find it difficult to keep appointments. Some homeless people may face similar challenges. A small body of research consistently indicates that some simple steps can improve referral rates:
Many people who are regular drug users have poor nutrition, either because available funds have been expended on drug use and/or because the drug use has impact on nutrition (for example, regular heavy alcohol use can impair food absorption; some drugs, such as amphetamine, suppress appetite). Poor nutrition can lead to general poor health and contribute to specific conditions (e.g., vitamin deficiencies associated with alcohol use can increase the risk of cognitive impairment). Ensuring that your clients are aware of the need for a regular and balanced diet and facilitating access to quality food can do much to help your clients reduce a wide range of problems associated with AOD use. If you are concerned about particular conditions, you may need to seek specialist health advice.
Providing a safe, secure and helping environment for homeless people is a central component of most, if not all, services for homeless people. By providing this service to people affected by AOD use, you will help alleviate immediate risks and concerns, but will also help engage them in an opportunity to improve the quality of their lives. Access to such an opportunity is an important part of reducing and moving away from AOD problems. You might do this by:
Some people might be satisfied and helped by the support and services you can offer and/or may be disinterested in referral to other services. Some may benefit from a referral to specialist support. If they are in supported accommodation, then an assessment might be carried out by a case-worker. This process is outlined in Assessment and referral. Some services may demand referral through a GP. If referral to a GP, or any other service, is indicated, remember the steps that can help effective referrals. In order to facilitate access, some services have established a working relationship with GPs who are willing to respond to a wide range of client health care needs.
Services for homeless people already do much to assist people affected by AOD use. Dealing effectively with immediate crises caused by intoxication can help ensure the safety of staff and homeless people. It might also create an opportunity to effectively engage the person in your service. Services have an important role in reducing harm and in recovery by helping clients improve the quality of their lives, assisting them to find a safe and secure environment, improving nutrition, helping people access a supportive and helping relationship and more formal referral when indicated.
The information contained in this guideline has been sourced from interviews with homeless people, focus groups with practitioners, consultation with experts in the field, and a review of homeless studies undertaken by researchers at the National Drug Research Institute, Ted Noffs Foundation, and St Bartholomew’s House for the Australian National Council on Drugs in 2007. The following references were cited in this information sheet:
Chamberlain, C., Johnson, G., & Theobald, J. (2007). Homelessness in Melbourne: Confronting the challenge: Centre for Applied Social Reserach, RMIT University, Melbourne.
Hodder, T., Teeson, M., & Buhrich, N. (1998). Down and Out in Sydney. Prevalence of mental disorder, disability and health service use among homeless people in inner Sydney: Research Group in Mental Health and Homelessness.
Ministerial Advisory Committee. (2000). Victorian homelessness strategy: consultation paper: Melbourne: Office of Housing.
Teesson, M., Hodder, T., & Buhrich, N. (2000). Substance use disorders among homeless people in inner Sydney. Social Psychiatry and Psychiatric Epidemiology, 35, 451-456.