Concerns and Experiences of Alcohol and Other Drug Healthcare Staff Regarding Intoxication Detection and Driving Safety of Opioid Treatment Clients

ABSTRACT

Introduction

Accurate detection and management of intoxication is critical in healthcare, particularly in alcohol and other drug (AOD) settings. While alcohol intoxication is often reliably assessed, drug intoxication is harder to detect. For clients receiving opioid agonist treatment (OAT), intoxication status can impact safety, treatment planning and driving eligibility. This study explores AOD healthcare staff confidence, training and concerns in managing intoxication and driving safety amongst OAT clients.

Method

A cross‐sectional survey was conducted with staff across 12 public AOD clinics in New South Wales, Australia. Data were collected on self‐reported confidence and training regarding client intoxication and driving safety, concerns and experiences managing intoxicated OAT clients, and substances of concern for intoxication and driving safety.

Results

Seventy‐nine staff (58% nursing, 19% allied health, 17% medical, 6% other) completed the survey, with a median of 7 years' AOD experience. Two‐thirds reported confidence managing intoxicated OAT clients, and 87% felt adequately trained. Key barriers to managing suspected intoxication included risk of aggression (72%), concern about upsetting clients (44%), and risk of incorrect assessment (38%). Half of staff (55%) reported encountering an intoxicated client in the past year. Substances of greatest concern for client intoxication and driving safety were benzodiazepines (95%), heroin (94%), alcohol (92%) and amphetamines (87%).

Discussions and Conclusions

While many AOD staff feel relatively confident identifying and managing client intoxication, they reported concerns around managing such scenarios. Ongoing training, alongside tools or structured frameworks, may support healthcare staff to better detect and manage intoxication and driving safety of clients.

1. Introduction

The timely and accurate detection of substance use intoxication is a critical component of clinical assessments in healthcare, particularly in high‐risk settings, such as emergency departments [1, 2], paramedicine [3, 4] and alcohol and other drug (AOD) treatment services [5, 6]. The rapid and accurate identification of intoxication can inform life‐saving decisions, helping clinicians to assess immediate risks such as overdose, injury, agitation or violent behaviour [7], and impaired operation of motor vehicles or machinery, with important implications for driving safety. In the context of AOD treatment, ‘driving safety’ refers to the clinical assessment and management of risks associated with clients operating a motor vehicle while intoxicated or impaired, including decisions regarding dosing, takeaways and client counselling on fitness to drive [8, 9].

Clinicians must also distinguish intoxication from other conditions with overlapping presentations, such as cognitive impairment, brain injury, ataxia or sleep deprivation [10, 11, 12]. While alcohol intoxication can often be assessed using a breathalyser [13, 14], drug intoxication presents a more complex challenge. Standard drug testing may confirm substance use but cannot determine current intoxication [15]. Moreover, intoxication symptoms vary widely depending on the type and combination of substances involved.

Clinicians frequently rely on patient history, behavioural cues and clinical judgement; however, research indicates that assessments of intoxication, even by experienced health professionals, are not always accurate. In one study conducted in an emergency trauma setting, clinicians correctly identified 77% of alcohol‐intoxicated patients but misclassified 26% of patients with a breath alcohol concentration (BAC) of zero as being intoxicated [16]. Similarly, another study of trauma clinicians found that 17% of patients with a non‐zero BAC were misclassified, with clinicians tending to overestimate the level of BAC based on clinical judgement [17]. In AOD treatment settings, accurate intoxication assessment is particularly important. Clients often present with complex substance use histories and may continue to use substances throughout their treatment journey [18]. Clinicians must be well‐trained in recognising and managing intoxication to ensure both patient safety and appropriate care responses. For opioid agonist treatment (OAT) clients, intoxication status informs both clinical safety and treatment planning, guiding assessments of health risks, treatment stability, eligibility for takeaway or pharmacy dosing and fitness to drive [8, 19]. Indeed, these factors can impact on where and how an OAT client may receive treatment. For example, a high‐risk client who regularly reports substance use and presents intoxicated may be required to present daily for medication dosing at a specialist clinic, whereas a lower‐risk client with no ongoing substance use is more likely to be eligible to receive their treatment at a community pharmacy and be given takeaway doses for later use [20].

For OAT clients, driving safety is a particularly critical consideration. Impairments related to medications or other substances can result in road trauma, legal consequences or treatment disruptions. Driving safety is a crucial issue in AOD treatment, but limited research has explored how clinicians experience, respond to and are trained to manage intoxicated clients who may pose a driving risk.

While several studies to date have explored intoxication training, detection and clinician attitudes in settings such as emergency departments and community pharmacies [5, 16, 21], research specific to AOD treatment clinic staff and non‐alcohol substance intoxication remains limited. To our knowledge, no previous studies have examined how AOD clinicians integrate driving safety considerations into their clinical decision‐making for OAT clients, or how confidence, training and perceptions of intoxication influence these decisions. This study aims to: (i) assess the confidence and training of AOD healthcare staff in managing intoxication detection and driving safety of OAT clients; (ii) understand the concerns and experiences of AOD healthcare staff managing suspected intoxication of OAT clients; and (iii) identify key substances of concern for clinicians regarding OAT clients.

2. Methods

2.1. Study Design and Sample

Between February 2020 and July 2021, a cross‐sectional survey with healthcare staff was conducted across 12 public AOD treatment clinics (eight metropolitan and four regional clinics, as per the Australian Statistical Geography Standard Remoteness Structure [22]) in New South Wales (NSW), Australia. Clinics were invited to participate via the Drug and Alcohol Clinical Research and Improvement Network (DACRIN), a collaborative group of drug and alcohol services in NSW. At the time, there were approximately 40 public clinics operating across 15 Local Health Districts in NSW.

Each clinic provides a range of treatment services for AOD issues, including OAT for the management of opioid dependence, with methadone or buprenorphine pharmacotherapies. The survey was distributed to staff via email, taking approximately 10–15 min to complete. Except for two clinics (due to local policies), staff who completed the survey were invited to submit an entry into a prize draw for one participant of each clinic to receive a $100 retail voucher.

2.2. Procedures and Measures

Staff were recruited via email distributed by a nominated non‐executive staff member within each organisation. The survey was completed by participants electronically on the secure web‐based platform, Research Electronic Data Capture (REDCap) [23].

The survey comprised items on staff demographics (age, gender, professional role, years of experience in AOD treatment settings). Questions regarding staff confidence and training in detecting and managing client intoxication, as well as concerns about client intoxication and driving safety for select substances (alcohol, cannabis, stimulants, heroin) and medications (methadone, buprenorphine, other opioids, benzodiazepines, antidepressants, antipsychotics, pregabalin, gabapentins, z‐drugs) were measured using five‐point Likert scales. Questions regarding staff concerns and experiences of intoxication assessments and management were presented as multiple‐choice items with predefined responses, including an option to provide additional ‘other’ responses. The study survey is included in Supporting Information, File S1.

2.3. Statistical Analyses

Data were analysed using IBM SPSS Statistics (Version 28.0) [24]. Of the 90 participants who commenced the survey, 11 (12%) had missing data on one or more variables and were excluded using listwise deletion, resulting in a final analytic sample of 79 participants. Descriptive statistics were summarised for the study variables. Likert data were dichotomised, with negative and neutral responses combined (e.g., ‘strongly disagree’, ‘disagree’ and ‘neither agree or disagree’) and positive responses combined (e.g., ‘agree’ and ‘strongly agree’). Non‐clinical respondents (e.g., administrative roles; n = 5) are described but then excluded from further statistical analyses given they are unlikely to be directly involved in clinical care.

Categorical data were analysed by χ ² tests, with Cramer's V to measure effect size. Fisher's Exact test was used where expected cell size assumptions (less than five for at least one cell) were not met. Where a test returned a statistically significant result, binary logistic regression was used to calculate the adjusted odds ratio (aOR) and 95% confidence intervals (CI). Gender, professional role, regionality and years of experience in AOD treatment settings were included as covariates to account for potential individual and service‐level differences that may influence staff‐reported outcomes [25, 26, 27]. Age was excluded from adjusted analyses due to strong positive collinearity with years of AOD experience (Pearson correlation: r = 0.602, p ≤ 0.001) [28]. Statistical significance for all tests was set at p < 0.05.

2.4. Ethics Statement

The research was approved by the Sydney Local Health District Ethics Review Committee (RPAH Zone; HREC 2019/ETH 10587). Site‐specific authorisations were provided by each participating Local Health District governance office.

3. Results

3.1. Demographics

Seventy‐nine staff participated in the study (Table 1). Most respondents reported working in nursing roles (58%), allied health (19%), medical (17%) or other non‐clinical roles (e.g., administrative staff; 6%). Participation amongst some groups, such as medical staff, was small and should be interpreted with caution. Participants were aged a median of 44 years (interquartile range 36–55 years), with three‐quarters identifying as female (75%) and located in a metropolitan area of NSW (73%). The median years of experience in the AOD field amongst participants was 7 years (interquartile range 2–15 years).

TABLE 1.

Demographics of staff participants by professional role.

Variable	Total, N = 79 n (%)	Professional role, n (%)
		Medical, n = 13 (17%)	Nursing, n = 46 (58%)	Allied health a , n = 15 (19%)	Other roles, n = 5 (6%)
Age (years), median (IQR)	44 (36–55)	43 (36–57)	49 (38–56)	37 (31–50)	44 (36–57)
Gender
Female	58 (75)	7 (12)	38 (64)	10 (17)	4 (7)
Male	19 (24)	6 (32)	8 (42)	4 (21)	1 (5)
Non‐binary/other	1 (1)	—	—	1 (100)	—
Clinic location b
Metropolitan	58 (73)	10 (17)	32 (55)	13 (23)	3 (5)
Regional	21 (27)	3 (14)	14 (67)	2 (10)	2 (10)
Years AOD experience (years), median (IQR)	7 (2–15)	6 (3–18)	7 (2–15)	9 (2–18)	3 (2–12)

Abbreviations: AOD, alcohol and other drugs; IQR, interquartile range.

^a Defined as per the NSW Health allied health professions: https://www.health.nsw.gov.au/workforce/alliedhealth/Pages/professions.aspx.

^b Based on the Australian Standard Geography Standard Remoteness Structure (2016) [22], with metropolitan areas equivalent to major city designation, and regional equivalent to all regional and remote designations.

3.2. Staff Confidence and Training

Two‐thirds of staff participants indicated they felt either somewhat confident (49%) or completely confident (18%; hereafter referred to as confident) in managing an intoxicated OAT client who indicates they intend to drive. Three‐quarters of nursing staff indicated confidence in managing intoxication and driving safety events (76%), compared to only half of medical (54%) and allied health (47%) staff. No significant associations were observed between confidence to manage an intoxicated client and professional role, gender, years of experience or regionality (p ≥ 0.065).

Regarding training, most staff indicated their current training with identifying and managing intoxication events as either somewhat adequate (64%) or completely adequate (23%; hereafter referred to as adequate). When asked about the type of training received, most responses referenced on‐the‐job or informal experience (39%) or ongoing clinical mentorship (14%), with few reporting self‐directed learning (11%) or formal intoxication‐specific training (8%). Regarding client driving safety, while the majority of staff (54%) reported having regular discussions on this topic, only around 20% had completed formal training addressing driving safety issues. Medical staff were most likely to report adequate training in intoxication (92%), compared to nursing (87%) and allied health (80%) staff.

An association between staff confidence and perceived adequacy of training (p < 0.042; Cramer's V = 0.281) was noted. In the adjusted binary logistic regression model, staff who perceived their training as adequate had significantly higher odds of reporting confidence in intoxication assessment (aOR 9.46; 95% CI 2.22–40.25), after adjusting for gender, professional role, regionality and years of experience.

When staff were asked about their interest in additional training on intoxication detection and management, 84% of staff expressed a desire for further learning. Amongst the different professional groups, allied health staff showed the highest interest (90%), followed by nursing (87%) and medical staff (69%). No significant differences were observed in terms of training adequacy or interest for further training across professional roles, gender, years of experience or regional location (p ≥ 0.298 and p ≥ 0.280 for training adequacy and interest for further training, respectively).

3.3. Concerns and Experiences of Client Intoxication

Staff indicated a range of concerns to addressing potential intoxication of OAT clients (Table 2), including concerns of aggression from a client (72%), a risk of upsetting a client (44%), incorrectly assessing intoxication (38%) and causing damage to the therapeutic relationship with a client (37%).

TABLE 2.

Staff reported concerns and past experiences when assessing intoxication and driving safety amongst opioid agonist treatment clients.

	Total, N = 79
	Concern, n (%)	Past experience, n (%)
Incorrect intoxication assessment
No	49 (62)	72 (91)
Yes	30 (38)	7 (9)
Risk of upsetting client
No	44 (56)	25 (32)
Yes	35 (44)	54 (68)
Aggression from client
No	22 (28)	34 (43)
Yes	57 (72)	45 (57)
Damage to therapeutic alliance
No	50 (63)	52 (66)
Yes	29 (37)	27 (34)
Privacy to discuss intoxication
No	70 (87)	77 (97)
Yes	9 (11)	2 (3)
Time‐related pressures
No	54 (68)	70 (89)
Yes	25 (32)	9 (11)
Staffing/capacity Issues
No	62 (78)	72 (91)
Yes	17 (22)	7 (9)

Staff were also asked whether they have had prior experience of these concerns. Reported past experiences included occasions of upsetting a client (68%), receiving aggression from a client (57%) and causing damage to the therapeutic relationship with a client (34%) when undertaking intoxication assessments. For several domains, reported concerns exceeded past experiences, whereas for others the opposite pattern was observed. Notably, concern regarding aggression was more frequently endorsed than prior experience of aggression, while past experience of upsetting a client was reported more often than concern about upsetting a client.

When asked if staff had an experience of managing a confirmed intoxicated presentation, 55% reported at least one occurrence in the previous 12 months, with 12% experiencing five or more intoxicated presentations during that period. No association was noted when examining prior experiences of managing an intoxicated presentation with confidence.

3.4. Substances of Concern

Substances that elicited the strongest concern amongst staff for OAT client intoxication and driving safety included benzodiazepines (95%), heroin (94%), alcohol (92%) and amphetamines (87%; Figure 1). Both alcohol and heroin had larger strongly agree responses (77% and 75%, respectively) than benzodiazepines (68%). Lower levels of concern were observed for methadone (58%), buprenorphine (52%) and antidepressant (35%) medications.

FIGURE 1.

Comparison of agree and strongly agree responses (ungrouped) versus disagree/neutral responses (grouped) by staff for the question ‘to what extent do you agree/disagree that the following substances and medications are of concern for opioid agonist treatment client intoxication and their driving safety?’

4. Discussion

This study underscores the important challenges faced by AOD health professionals in managing potential intoxication and driving safety concerns amongst OAT clients. Staff reported variable levels of confidence and prior training, with over half (55%) encountering at least one intoxication‐related presentation in the past 12 months. Confidence in managing an intoxicated client who intends to drive (67%) was also variable across staff. Many staff also expressed interest in additional training and support, suggesting a need for ongoing professional development to promote consistency in clinical practise and decision‐making. Importantly, staff who perceived their training as adequate had significantly higher odds of reporting confidence in intoxication assessment, even after adjusting for demographic and professional characteristics.

Staff also described a range of difficult experiences when managing intoxicated clients, including the risk of upsetting clients, encountering aggression and protecting the therapeutic relationship. These challenges underscore the emotional and interpersonal complexity of responding to suspected intoxication and point to potential impacts on client engagement and treatment outcomes. Providing staff with targeted communication training, de‐escalation strategies and clinical supervision may help mitigate these risks. Similarly, client education and support is also warranted, ensuring those receiving OAT are aware of the impact ongoing substance use may have on their treatment (e.g., more regular reviews, reduced takeaway doses, etc.) and the impact on their fitness to drive [29].

Driving safety in AOD treatment involves assessing and managing the risk of clients operating motor vehicles while intoxicated, including decisions regarding dosing schedules, takeaways and counselling on fitness to drive. Detecting intoxication and accurately assessing levels of impairment remain a persistent challenge. While breathalysers can objectively assess alcohol intoxication, no single measure exists for other drugs, so clinicians often rely on a combination of clinical judgement, behavioural observation and patient self‐report. Current structured frameworks use these observable signs and subjective assessments, [30], but misdiagnosis is still possible, with potentially serious clinical and safety consequences [31, 32]. In the context of driving a motor vehicle, inaccurate assessment of intoxication may have serious consequences, posing risks to both the client and the general public [33]. Our findings highlight that clinician confidence in managing client intoxication and driving safety is variable, reinforcing the importance of structured guidance and decision‐support tools to promote consistent practise and safeguard both clients and the general public.

Although few studies have examined intoxication management specifically within AOD settings, broader healthcare literature highlights similar challenges. For example, one study of rural NSW emergency departments found that 9% of presentations involved alcohol intoxication, with clinicians identifying 6% as alcohol‐related; the authors suggested these figures likely underestimate the true prevalence [34]. Similarly, historical research on community pharmacists indicated gaps in training and confidence when managing intoxicated clients [5]. These findings suggest that the challenges identified in our study may extend across healthcare settings, emphasising the need for consistent training frameworks and support mechanisms.

This study recruited staff from public AOD treatment services across NSW, Australia, with data collected via an anonymous, cross‐sectional survey distributed by email. Participants included medical, nursing, allied health and other roles, though there is likely variation within these categories. For example, allied health may include pharmacists and social workers, who bring diverse clinical perspectives and training. This study was conducted during the peak of the COVID‐19 pandemic, which may have affected participation due to heightened clinical demands and burnout [35, 36]. The overall sample size was modest and the cross‐sectional design limits causal inference. Subgroup analyses by professional role were exploratory and may have been underpowered due to small cell sizes. Participation of some health profession groups, such as medical and allied health staff, was low in absolute number; however, this partly reflects the typical staffing composition in NSW public AOD services [25]. The response rate for the study was also not obtained. Despite these limitations, the study addresses an important gap by exploring client intoxication and related driving safety issues in AOD settings.

Many participants reported substantial experience managing intoxicated presentations. However, all data were self‐reported, and therefore responses may have been influenced by social desirability bias or subjective perceptions of confidence and training adequacy. The sample consisted of AOD health professionals who regularly work with people who use drugs. Therefore, findings may not be generalisable to staff with less AOD experience or those working in non‐specialist settings. We also note this study did not assess actual clinical performance or outcomes, limiting the ability for this research to correlate reported confidence with real‐world effectiveness.

Future research could examine the concerns and experiences of other health professionals who engage with people who use drugs, including non‐government treatment services, general practitioners and community pharmacists. Studies could also examine the impact of training on intoxication detection and driving safety decision‐making, as well as the ability of health professionals to accurately identify intoxication. It is also important to examine suspected intoxication cases, including situations where intoxication is suspected but not confirmed, or where behaviours may have other causes. There is also a need to develop and validate tools or structured frameworks to aid clinicians in detecting intoxication from a range of substances beyond alcohol. Comparative studies across different healthcare sectors could identify where targeted training is most needed and how cross‐sector collaboration might support consistent practise. Future studies with larger and more balanced samples are needed to determine whether meaningful differences exist across professional roles within the AOD workforce. These issues extend beyond healthcare, as research indicates that both law enforcement and lay people often struggle to accurately identify intoxication [37, 38].

AOD health professionals face complex clinical, interpersonal and safety challenges when managing intoxicated presentations and associated driving safety issues. While many staff reported confidence and experience, variability in perceived training adequacy was strongly associated with confidence in managing intoxication and driving safety scenarios. These findings underscore the need for targeted training and ongoing professional development for staff to navigate complex, high‐risk intoxication and driving safety scenarios while maintaining therapeutic relationships and promoting both client and public safety.

Author Contributions

Daniel T. Winter: conceptualisation; data curation; formal analysis; investigation; project administration; writing – original draft preparation. Gabriel A. Verón: formal analysis; writing – review and editing. Carolyn A. Day: investigation; methodology; supervision; validation; writing – review and editing. Nicholas Lintzeris: conceptualisation; methodology; writing – review and editing. Paul S. Haber: conceptualisation; funding acquisition; methodology; resources; supervision; writing – review and editing. Lauren A. Monds: conceptualisation; methodology; supervision; validation; writing – review and editing.

Funding

This work was supported by a NSW Ministry of Health grant related to opioid pharmacotherapy and client driving safety.

Conflicts of Interest

Paul Haber has received research funding from Indivior and Camurus for opioid‐related research and is the recipient of a Medical Research Future Fund/National Health and Medical Research Council Practitioner Research Fellowship. Nicholas Lintzeris has received research funding from Camurus and Indivior for opioid‐related research. The other authors declare no conflicts of interest.

Supporting information

Data S1: dar70144‐sup‐0001‐Supinfo.docx.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.