Chemical restraint in custody: national trends, clinical outcomes, and policy implications (2022-2025)

Chemical restraint in police-involved prehospital encounters remains a critical public health and human rights issue. Despite the formal rejection of "excited delirium" as a medical diagnosis by major professional organizations in 2022, sedative medications, particularly ketamine, continue to be administered in custodial settings under coercive and clinically unstable conditions. Emerging evidence from the past five years demonstrates persistent mortality risk, high rates of airway compromise, and pronounced racial inequities associated with these practices.

This manuscript synthesizes peer-reviewed clinical research, national investigative reporting, and legal analyses published between 2020 and 2025 to evaluate outcomes associated with chemical restraint during law-enforcement encounters. It further examines why the term "excited delirium" is clinically invalid and ethically harmful, how law enforcement presence disrupts medical decision-making in the field, and what protocol reforms are necessary to improve patient safety.

This narrative review of peer-reviewed studies, government reports, and investigative datasets addressing prehospital sedation, ketamine use, restraint-related deaths, and racial disparities calls attention to the ongoing concern. The inclusion criteria emphasized U.S.-based data, custodial or police-involved settings, and publications from within the past five years.

Evidence consistently shows that prehospital ketamine administration is associated with significantly higher intubation and respiratory complication rates than comparable emergency department use. Black individuals are disproportionately subjected to chemical restraint, often justified through racialized behavioral labels historically associated with "excited delirium." Protocol fragmentation and law enforcement influence on clinical care remain central contributors to preventable harm.

Chemical restraint in custody settings represents a convergence of unsafe clinical practice and structural inequity. National protocol reform, elimination of "excited delirium" terminology, strengthened medical oversight, and interruption mechanisms when unsafe dosing occurs are urgently required to protect patient safety and advance health equity.